The antimicrobial effectiveness of 25% propolis extract in root canal irrigation of primary teeth

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1JOURNAL CLUB PRESENTATION ADITI SINGH P.G DEPT OF PAEDODONTICSSDCH ,RISHIKESHThe antimicrobial effectiveness of 25% propolis extract in root canal irrigation of primary teethKumar MV, Pandey RK, Khanna R, Agarwal J.J Indian Soc Pedod Prev Dent 2014;32:120-4INTRODUCTION AIM MATERIALS & METHODOLOGYTECHNIQUERESULTSDISCUSSIONCONCLUSION

INTRODUCTIONBacteria are the major cause of pulpal and periapical diseases. Main objective of endodontic therapy is clean sterile root canals which can be sealed of at the apex.Complexity of the root canal system, invasion of the dentinal tubules by microorganisms, formation of smear layer during instrumentation and presence of dentin as a tissue are the major obstacles for complete elimination of bacteria during cleaning and shaping of root canal systems.American Association of Endodontists Guidelines for Rootcanal Irrigants & disinfectants;Endodontics Colleagues for excellence;2011(2011):1-8IRRIGATING SOLUTIONSIntracanal irrigants are solutions that exert their effects mechanically and chemically. Mechanical effects of irrigants are generated by the back and forth flow of the irrigation solution during cleaning and shaping of the infected root canals, significantly reducing the bacterial load.American Association of Endodontists Guidelines for Rootcanal Irrigants & disinfectants;Endodontics Colleagues for excellence;2011(2011):1-8IDEAL IRRIGATING SOLUTION To effectively clean and disinfect the root canal system, an irrigant should be able to disinfect and penetrate dentin and its tubules, offer long-term antibacterial effect (substantivity), It must remove the smear layerIt must be nonantigenic, nontoxic and noncarcinogenic. In addition, it should have no adverse effects on dentin or the sealing ability of filling materials.It should be relatively inexpensive, convenient to apply and cause no tooth discoloration. Other desirable properties for an ideal irrigant include the ability to dissolve pulp tissue and inactivate endotoxins.American Association of Endodontists Guidelines for Rootcanal Irrigants & disinfectants;Endodontics Colleagues for excellence;2011(2011):1-8Broad antimicrobial spectrumHigh efficacy against anaerobic and facultative microorganisms organized in biofilmsAbility to dissolve necrotic pulp tissue remnantsAbility to inactivate endotoxinAbility to prevent the formation of a smear layer during instrumentation or to dissolve the latter once it has formed.Systemically nontoxic when they come in contact with vital tissues, noncaustic to periodontal tissues, and with little potential to cause an anaphylactic reaction

Kandaswamy D, Venkateshbabu N; Root canal irrigants; J Conserv Dent. 2010 Oct-Dec; 13(4): 256264.DIFFERENT IRRIGATING SOLUTIONS(CLASSIFICATION)

Kandaswamy D, Venkateshbabu N; Root canal irrigants; J Conserv Dent. 2010 Oct-Dec; 13(4): 256264.SODIUM HYPOCHLORITESodium hypochlorite (household bleach) is the most commonly used root canal irrigant. It is an antiseptic and inexpensive lubricant that has been used in dilutions ranging from 0.5% to 5.25%. Mechanism of Action : Free chlorine in NaOCl dissolves vital and necrotic tissue by breaking down proteins into amino acids.Decreasing the concentration of the solution reduces its toxicity, antibacterial effect and ability to dissolve tissues.Increasing its volume or warming it increases its effectiveness as a root canal irrigant.American Association of Endodontists Guidelines for Rootcanal Irrigants & disinfectants;Endodontics Colleagues for excellence;2011(2011):1-8advantagesdisadvantages1. ability to dissolve organic substances present in the root canal system and its affordabilitycytotoxicity when injected into periradicular tissues, Foul smell and taste, ability to bleach clothes and ability to cause corrosion of metal objects.it does not kill all bacteria,it does not remove all of the smear layer.It also alters the properties of dentin.The results of a recentin vitro study show that the most effective irrigation regimen is 5.25% at 40 minutes, whereas irrigation with 1.3% and 2.5% NaOCl for this same time interval is ineffective in removing E. faecalis from infected dentin cylindersAmerican Association of Endodontists Guidelines for Rootcanal Irrigants & disinfectants;Endodontics Colleagues for excellence;2011(2011):1-8CHLORHEXIDINEIt has a broad-spectrum antibacterial action, sustained action and low toxicity.Its used as intra canal medicament due to its substantivity and long-lasting antimicrobial effect, which arises from binding to hydroxyapatite.Mechanism of action : It has a cationic molecular component that attaches to negatively charged cell membrane areas, causing cell lysis.Its property to bind with hydoxyapatite crystal The major advantages of chlorhexidine over NaOCl are its lower cytotoxicity and lack of foul smell and bad taste. However, unlike NaOCl, it cannot dissolve organic substances and necrotic tissues present in the root canal system. In addition, like NaOCl, it is unable to kill all bacteria and cannot remove the smear layer.American Association of Endodontists Guidelines for Rootcanal Irrigants & disinfectants;Endodontics Colleagues for excellence;2011(2011):1-8EDTAChelating agents such as ethylene diamine tetraacetic acid (EDTA), citric acid and tetracycline create a stable calcium complex with dentin mud, smear layers, or calcific deposits along the canal walls. This may help prevent apical blockage and aid disinfection by improving access of solutions through removal of the smear layer.NaOCl is an adjunct solution for removal of the remaining organic components. Irrigation with 17% EDTA for one minute followed by a final rinse with NaOCl is the most commonly recommended method to remove the smear layer.Longer exposures can cause excessive removal of both peritubular and intratubular dentin.EDTA has little or no antibacterial effectAmerican Association of Endodontists Guidelines for Rootcanal Irrigants & disinfectants;Endodontics Colleagues for excellence;2011(2011):1-8IKIIodine potassium iodide (IKI) is a traditional root canal disinfectant and is used in concentrations ranging from 2% to 5%. Mechanism of Action : IKI kills a wide spectrum of microorganisms found in root canals but shows relatively low toxicity in experiments using tissue cultures.Iodine acts as an oxidizing agent by reacting with free sulfhydryl groups of bacterial enzymes, cleaving disulfide bonds. E. faecalis often is associated with therapy-resistant periapical infections, and combinations of IKI and CHX may be able to kill Ca(OH)2-resistant bacteria more efficiently.MTAD (mixture of a tetracycline isomer, an acid (citric acid) and a detergentAn alternative solution to EDTA for removing the smear layer is the use of BioPure MTAD (DENTSPLY Tulsa Dental Specialties, Tulsa, Okla.), a mixture of a tetracycline isomer, an acid (citric acid) and a detergent. MTAD was developed as a final rinse to disinfect the root canal system and remove the smear layer. The effectiveness of MTAD to completely remove the smear layeris enhanced when a low concentration of 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.In addition, it has sustained antibacterial activity, is biocompatible and enhances bond strengthAmerican Association of Endodontists Guidelines for Rootcanal Irrigants & disinfectants;Endodontics Colleagues for excellence;2011(2011):1-8HYDROGEN PEROXIDEH2O2 kills aneaerobic bacteriaCombined with sodium hypochlorite it removes the debris due to effervescence effect of peroxide .Drawback of this solution : ephysema due to liberation of oxygen bubbles into the soft tissue.So it cannot be used under strong pressureConc. Of Hydrogen peroxide to be used safely is 3% .CHLORAMINENon toxic non irritant in small conc.Used in 1-5% conc. Most frequently 2% for irrigationIn combination with Hydrogen peroxide it produces oxygen & chlorine which have antimicrobial & better dissolving & depurative effect.Kovac J,Kovac D; Effect of irrigatin solutions in endodontic therapy ; Bratisl Lek Listy ;2011;112(7)

Cohen S, Hargreaves K ; Cohens Pathway of pulp;2011;10 Ed Mosby Elsevier

Cohen S, Hargreaves K ; Cohens Pathway of pulp;2011;10 Ed Mosby Elsevierother irrigantsElectrochemically activated water (also known as oxidative potential water)Hydrogen peroxide traditionally has been used as an irrigant in conjunction with NaOCl.0.2% or 0.5% CHX in addition to NaOCl, either as an irrigant or mixed with Ca(OH)2 as an interappointment medicament. These combinations can overcome the inhibiting effect of dentin dust on conventional medicaments and can optimize their antimicrobial properties against certain resistant bacteria and yeastsNaOCl with a final 17% EDTA rinse with an equal mixture of 2% NaOCl and 18% etidronic acid during and after instrumentation and a protocol involving 1% NaOCl during preparation and 2.25% peracetic acid after instrumentation.Cohen S, Hargreaves K ; Cohens Pathway of pulp;2011;10 Ed Mosby ElsevierIRRIGATION DEVICES AND TECHNIQUES

PROPOLIS: THE NATURAL PENICILLINPropolis is a natural product that has gained increased interest due to its antimicrobial activity against a wide range of pathogenic microorganisms.COMPOSITION : resin and balsams (50-60%), pollen (5-10%),other constituents like amino acids, minerals, vitamins A and B complex,Highly active biochemical substance known as biofl avonoids (vitamin P), phenols, and aromatic compounds.USES IN DENTISTRYPropolis has been used in dentistry asAs storage media for avulsed teeth,For prevention of caries,Dentine hypersensitivityPulp capping agentMahmoud AS, Almas K, Dahlan AA. The effect of propolis on dentinal hypersensitivity and level of satisfaction among patients from a university hospital Riyadh, Saudi Arabia. Indian J Dent Res 1999;10:130-7AIM To assess the potential of water-soluble 25% propolis extract against microorganisms present in root canals of primary teeth during endodontic procedures.MATERIAL & METHODOLOGYSAMPLE SIZE : 70 Primary teeth were selected divided in 2 groups based on the irrigating solution usedGroup A consisted of 35 subjects with 0.9% isotonic saline as an irrigating solution. Group B : consisted of 35 subjects with 25% water-soluble propolis as an irrigating solutionINCLUSION CRITERIA : The patients in the age group of 4-7 years, having good general health, without history of antibiotic coverage and radiographic evidence of carious pulp exposure in primary teeth with restorable tooth structure.Teeth with necrotic pulp.Atleast 2/3rd of root length of the tooth must be presentEXCLUSION CRITERIA : The clinical and radiographic evidence of pathosis in periapical or furcation area and presence of internal/external resorptionRoot resorption not more than 1/3rd of root length.Informed consent was taken from the parent & guardian of patients involved in the study.The techniqueFor lab analysis RESULTSGroup AGroup BPre irrigationPost irrigationPre irrigationPost irrigationStreptococci2400017000220006000Staphylococci22000180002400013000E fecalis1500010000160007000Ecoli80005000100005000Mean change in bacterial colony counts :Streptococci : 59.2%Staphylococci : 68.2%E fecalis : 52.3%E coli : 37.4%DRAWBACKS OF THE STUDYSample collection with adsorbent paper point is insufficient to collect those from lateral accessory canals , apical ramifications or dentinal tubules & deeper areas etc.Primary teeth infections are polymicrobial in nature with more types of pathogens involved , that could not be isolated in this study.Method of isolation & identification used was insufficient to isolate the uncultivable & fastidious microbes.Only quantitative antibacterial effects of propolis assessed.Sodium hypochlorite & Chlorhexidine are the irrigants of choice in permanent as well as primary teeth which were not included in the study Water extract of propolis as claimed by the authors doesnt affect the biological activity of propolis, indeed was found to decrease its efficacy though , when compared by its resinous extract or lipid extract.

PROPOLIS : PROS & CONSFAVOUR AGAINST Silva et al : propolis is least irritating solution (less than Saline)Ramos etal : less inflammatory than corticosteroids antibiotic preparation in periapical region.Najafi et al : water extract of propolis retained most of its flavanoids , so didnt affect its biological propertiesArslan et al : propolis is an effective intracanal irrigant in eradicating E. faecalis and C. albicans.Madhubala et al : ethanolic extract of propolis was more effective than tri antibiotic paste at the end of 2 days against E.fecalisValera et al : propolis + saline irrigation erradicated E.coli completely Chemical variability of different types of propolis .Difficult to manipulate as naturally its a lipid derivative resin material.Procurement of pure 100% propolis is difficult as it can get easily contaminated by pollutants & heavy metals .May not be safe for asthamatic patients , patients having allergic tendencies, increased immune response.Potent anaphylactic reaction possible.CONCLUSIONPropolis is an excellent natural antibiotic with multiple health benefits.However owing to different biochemical properties depending upon its origin data is still insufficient about its safety.Being resin based in nature more formulations need to be found out & tested ; that can make it easy to use in a small working area like a root canal making it a more tangible option for endodontic therapy.REFERENCES Silva FB, Almeida JM, Sousa SM. Natural medicaments in endodontics a comparative study of the anti-inflammatoryaction. Braz Oral Res 2004;18:174-9.Ramos IF, Biz MT, Paulino N, Scremin A, Della Bona A, Barletta FB, et al. Histopathological analysis of corticosteroidantibiotic preparation and propolis paste formulation as intracanal medication after pulpectomy: An in vivo study. J Appl Oral Sci 2012;20:50-6.Arslan S, Ozbilge H, Kaya EG, Er O. In vitro antimicrobial activity of propolis, BioPure MTAD, sodium hypochlorite, and chlorhexidine on Enterococcus faecalis and Candida albicans. Saudi Med J 2011;32:479-83Ruvire DB, Leonardo MR, da Silva LA, Ito IY, Nelson-Filho P. Assessment of the microbiota in root canals of human primary teeth by checkerboard DNA-DNA hybridization. J Dent Child (Chic) 2007;74:118-23.Najafi MF, Vahedy F, Seyyedin M, Jomehzadeh HR, Bozary K. Effect of the water extracts of propolis on stimulation and inhibition of different cells. Cytotechnology 2007;54:49-56Mahmoud AS, Almas K, Dahlan AA. The effect of propolis on dentinal hypersensitivity and level of satisfaction among patients from a university hospital Riyadh, Saudi Arabia. Indian J Dent Res 1999;10:130-7Kandaswamy D, Venkateshbabu N; Root canal irrigants; J Conserv Dent. 2010 Oct-Dec; 13(4): 256264.American Association of Endodontists Guidelines for Rootcanal Irrigants & disinfectants;Endodontics Colleagues for excellence;2011(2011):1-8Madhubala MM, Srinivasan N, Ahamed S. Comparative evaluation of propolis and triantibiotic mixture as an intracanal medicament against Enterococcus faecalis. J Endod 2011;37:1287-9.Roane JB, Dryden JA, Grimes EW: Incidence of postoperative pain after single- and multiple-visit endodontic procedures. Oral Surg Oral Med Oral Pathol 55:68, 1983.Roghanizad N, Jones JJ: Evaluation of coronal microleakage after endodontic treatment. J Endod 22:471, 1996.Ricucci D, Grondahl K, Bergenholtz G: Periapical status of root-filled teeth exposed to the oral environment by loss of restoration or caries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90:354, 2000Pashley DH: Smear layer: overview of structure and function. Proc Finn Dent Soc 88:215, 1992