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Table of Contents   
ORIGINAL ARTICLE  
Year : 2020  |  Volume : 23  |  Issue : 5  |  Page : 528-532
Homeopathic consideration for resistant endodontic bacteria Enterococcus faecalis: An in vitro comparative disc diffusion study


1 Department of Conservative Dental Sciences and Endodontics, College of Dentistry, Qassim University, Saudia Arabia
2 Department of Conservative Dentistry and Endodontics, Bhabha College of Dental Sciences, Bhopal, Madhya Pradesh, India

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Date of Submission16-Oct-2020
Date of Acceptance04-Jan-2021
Date of Web Publication10-Feb-2021
 

   Abstract 

Background: Homeopathy is one of the commonly used systems of complementary or alternative medicine. The present study was conducted with an aim to compare the antibacterial efficacy of two commonly used homeopathic medicaments acid benzoicum 30C (SBL Pvt Ltd) and silicea 6C (SBL Pvt Ltd) with that of calcium hydroxide (Deepti Ltd) as intracanal medicament against Enterococcus faecalis (ATCC-29212).
Materials and Methods: The test organism used for the study was E. faecalis. Petri plates with 20 ml of sheep blood agar were inoculated with 0.1 ml of the microbial suspensions. The medicaments to be tested for antimicrobial efficacy against E. faecalis were divided into three groups: Group A (acid benzoicum), Group B (silicea), and Group C (calcium hydroxide). The antimicrobial activity of each medicament was measured and expressed in terms of the mean of the diameter of zone of inhibition (in mm) produced by each extract at the end of the incubation period. ANOVA and Tukey's honestly-significant difference posthoc test were used for the intergroup comparison. P < 0.05 was considered statistically significant.
Results: Group A (acid benzoicum) showed the maximum zone of inhibition against Gram-positive E. faecalis (17.2 ± 0.65), and the difference between the groups related to the antibacterial activity was highly significant (P < 0.001). A statistically significant difference was observed between the three groups on the intergroup comparison (P < 0.001).
Conclusion: In the present in vitro study, antimicrobial activity of the acid benzoicum extract was the highest followed by silicea extract and then calcium hydroxide.

Keywords: Antimicrobial property; disinfection; Enterococcus faecalis; failed root canal treatment; homeopathy; root canal medicament

How to cite this article:
Dutta SD, Maria RD. Homeopathic consideration for resistant endodontic bacteria Enterococcus faecalis: An in vitro comparative disc diffusion study. J Conserv Dent 2020;23:528-32

How to cite this URL:
Dutta SD, Maria RD. Homeopathic consideration for resistant endodontic bacteria Enterococcus faecalis: An in vitro comparative disc diffusion study. J Conserv Dent [serial online] 2020 [cited 2021 May 17];23:528-32. Available from: https://www.jcd.org.in/text.asp?2020/23/5/528/309027

   Introduction Top


Root canal therapy aims at the removal of the infected pulp tissue from the root canal system followed by the disinfection and three-dimensional sealing of the same with an inert material like gutta-percha.[1] Irrigants and intracanal medicaments enable in achieving chemical disinfection by reducing the bacterial load but fail to completely disinfect the root canal system owing to its complex anatomy.

Incomplete disinfection of the root canal is also caused due to the resistance of the microorganism for a particular antibiotic resulting in endodontic infections. Among those, the most resistant bacteria in the root canal is Enterococcus faecalis which is a facultative anaerobic Gram-positive coccus has the ability to survive even in harshest of environments and has several virulence factors that are responsible for its infective efficacy. In primary endodontic infection, the prevalence of E. faecalis is about 40%, and in persistent or secondary endodontic infection, it reaches up to 77%.[2],[3]

Apart from being unable to achieve complete disinfection, intracanal medicaments such as calcium hydroxide cause collagen breakdown and hence weakening of radicular dentin thus predisposing the tooth to fracture.[4] Triple antibiotic paste using minocycline, metronidazole, and ciprofloxacin have potential side effects of tooth discoloration and demineralization of dentin.

Owing to the resistance of E. faecalis and side effects associated with intracanal medicaments such as calcium hydroxide and triple antibiotic paste, a search should be initiated for an alternative material having antibacterial potential that can attain the maximum disinfection of the root canal system and at the same time would be safe and economical.

Homeopathy is an alternative system of medicine that has been in the use for more than thousands of years. Homeopathic remedies have had an impact on the medical and dental practice because of the antimicrobial activity, biocompatibility, anti-inflammatory properties, easy availability, cost-effectiveness, increased shelf life, and lack of microbial resistance.[5],[6],[7]

It is a medical philosophy that views the symptoms of illness as normal responses of the body as it attempts to regain health. It works on the principle of “like cures like,” i.e., it uses minute concentrations of natural substances to cure the disease which in higher amounts would produce the symptoms of the disease.[8],[9] Acid benzoicum and silicea are two such homeopathic remedies that have the antibacterial potential to cure ailments. Acid benzoicum is prepared from benzoic acid, which is derived from the gum of the Calophyllum inophyllum plant which is known for its pharmacological activities since the 18th century.[10] Silicea or silica is derived from the quartz or flint and is a mineral present in the crust of the earth. Its remarkable action can even replace a surgeon's knife.[11]

The urge to combat bacterial resistance toward antibiotics and the ineffectiveness of other currently available intracanal medicaments has inspired us to conduct this study. To the best of our knowledge, no such study, comparing the antibacterial efficacy of homeopathic medicine with that of calcium hydroxide has been published in the literature. Our study is the first study of its kind, conducted with an aim to compare the antimicrobial potential of acid benzoicum and silicea with calcium hydroxide against a resistant endodontic bacteria E. faecalis.


   Materials and Methods Top


The test organism used for the study was E. faecalis, which is a Gram-positive facultative anaerobic bacterium. The strain of E. faecalis (ATCC 29212) was obtained by the microbiology laboratory.

Three root canal medicaments were selected to determine their antimicrobial activity against E. faecalis. The homeopathic agents were used in the recommended concentration of Silicea 6C and acid Benzoicum 30C.

They were divided into three groups: Group A (acid benzoicum), Group B (Silicea), and Group C (calcium hydroxide), of which the first and second groups are the homeopathic medicines, and the third group is the most common commercially available root canal medicament.

Sheep blood agar was used as an enriched media for the growth of E. faecalis. Petri plates with 20 ml of sheep blood agar were inoculated with 0.1 ml of the microbial suspensions, using sterile swabs that were spread on the medium, obtaining growth incubation in n = 20 petri dish each. Sterile paper discs 10 mm diameter (hi-media) were immersed in the experimental solutions for 1 min or until completely soaked. Subsequently, three paper discs containing one of the substances were placed on the sheep blood agar in each agar plate. The plates were incubated at 37°C for 24 h. The diameter of microbial inhibition was measured around the paper discs containing the substances. The experiment was performed and repeated under strict aseptic conditions. The antimicrobial activity of each extract was expressed in terms of the mean of the diameter of zone of inhibition (in mm) produced by each extract at the end of the incubation period. All the measurements of the zone of inhibition were carried out by a single examiner. The examiner was calibrated to minimize the interexaminer variability. Scientific validity and reliability were confirmed by the interexaminer agreement score as described By Landis and Koch.

The results were tabulated and statistically analyzed using the SPSS software version 23.0 (SPSS Inc., Chicago, IL, USA). Kruskal–Wallis one-way ANOVA was used to compare between the three groups and intergroup comparison of antimicrobial activity was done using Tukey's honestly-significant difference post hoc test. P < 0.05 was considered statistically significant.


   Results Top


The results were tabulated and statistically analyzed using the SPSS software version 23.0 (SPSS Inc., Chicago, IL, USA). One-way ANOVA was used to compare between the groups. We found that the Group A (acid benzoicum) showed the maximum zone of inhibition against Gram-positive E. faecalis (17.2 ± 0.65) followed by Group B (silicea, 12.5 ± 1.04) and Group C (calcium hydroxide, 7.1 ± 1.07). On comparison, we found that the difference between the groups related to the antibacterial activity was highly significant (P < 0.001) [Table 1] and [Figure 1].
Table 1: Comparison of antimicrobial activity among study samples against Enterococcus faecalis culture

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Figure 1: (a-f) showing zone of inhibition with various observed with tested medicaments

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A statistically significant difference was observed between the three groups on the intergroup comparison (Group A vs. Group B, Group B vs. Group C, and Group A vs. Group C) (P < 0.001) [Table 2].
Table 2: Intergroup comparison of antimicrobial activity among study samples against Enterococcus faecalis culture using Tukey's honestly significant difference post hoc test

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   Discussion Top


Successful endodontic treatment depends on many factors, of which effective chemo-mechanical preparation of the apical third of the root canal system is the most important one.[12] Proper instrumentation and the use of the root canal medicament with good antimicrobial activity kills a majority of the microorganisms present in the root canal system, but a small amount of microflora still persists.[13] The persistence of the bacteria or microflora in the root canal depends upon the ability of the endodontic medicament to provide complete protection against bacteria and the type of bacterial species. Among a number of aerobic, anaerobic, Gram-positive, and Gram-negative bacterial species, E. faecalis, a facultative anaerobic Gram-positive coccus is the most common species that persists in the root canal and is also the most resistant to endodontic medicaments; hence, the most common cause of endodontic failure.[14],[15] E. faecalis was chosen as the test organism in this because it is a facultative organism that is easy to grow and nonfastidious. Sundqvist et al. in their study found that E. faecalis was recovered from about 38% of failed root canal-treated teeth and was thus the most commonly isolated bacteria from failed root canal systems.[16] The following factors are responsible for its resistance: (a) it can survive in a harsh environment or tolerate starvation, high pH, and high salt concentration; (b) mode of growth is by the formation of biofilm; and (c) has several virulence factors.[17] A root canal medicament or irrigant which not only eliminates the infection but also prevent reinfection of the root canal treated tooth should be introduced.

Homeopathic medicine was developed in the late 18th century by Samuel Hahnemann, a respected doctor in Germany. Its concept of like cures like is sometimes used in conventional medicine. For example, small doses of allergens such as pollen are sometimes used to desensitize allergic patients. An important difference, however, is that the medicinal doses used are so small that toxic effects are avoided. It could thus be a safe, gentle, and nontoxic choice that can be opted.[18]

In the present study, two homeopathic solutions (acid benzoicum and silicea) were tested for their antibacterial efficacy as an intracanal medicament. The results of our study showed that acid benzoicum has the maximum zone of inhibition and thus highest antibacterial activity amongst the three groups; and the difference was statistically significant. Acid benzoicum is a homeopathic remedy derived from the gum of the plant of C. inophyllum.[10] It has been used since ancient times for the treatment of various diseases such as orchitis, tonsillitis, and other several medical conditions, but recently, they have gained renewed interest and importance due to the increased number of resistant strains to antibiotics and the side effects associated with synthetic drugs.[19] Ghosh et al. also found that the higher potency of the homeopathic drug shows a bacteriostatic effect.[20] The probable mechanism of action of homeopathic solution or drug depends on their chemical composition. The particles of the homeopathic medicaments attach to the membrane of the bacterial cell by electrostatic interaction and disrupt the integrity of the cell membrane, this in turn is responsible for their antibacterial effect.[21]

In the present study, antibacterial efficacy of calcium hydroxide was compared with the two homeopathic solutions. The antimicrobial mechanism of calcium hydroxide is due to the slow dissociation of the compound into calcium and hydroxyl ions into the root canal space and its high pH (12.5). These hydroxyl ions are highly oxidant free radicals that damage the DNA of microorganisms, disrupt the cell membrane, and are responsible for protein denaturation.[22] Although calcium hydroxide is the most commonly used intracanal medicament in endodontics, the results of our study shows that E. faecalis was almost resistant to calcium hydroxide paste and the zone of inhibition observed was less, which demonstrates the inability of calcium hydroxide to kill the bacteria. The findings of our study are in accordance with many other studies.[23],[24],[25],[26] Kurian B et al. also found that antibacterial activity of the herbal extract was the highest followed by calcium hydroxide against E. faecalis bacteria.[17] Gomes et al. found that E. faecalis are resistant to calcium hydroxide when used as an intracanal medicament.[27] According to Sundqvist et al., calcium hydroxide is not very effective in removing all types of bacteria from the root canal.[16] Endodontic literature has suggested the probable reason for the resistance of E. faecalis bacteria. It was shown in the literature that a buffering action to the bacteria is provided by the dentin as E. faecalis deeply penetrates into the dentin where the medicament is unable to reach. Kowalski et al. found that E. faecalis penetrates up to the depth of 1483.33 μm inside dentinal tubules.[28] Heling et al. found that calcium hydroxide did not show any antibacterial activity against E. faecalis present inside dentinal tubule and failed to disinfect the dentin or prevent secondary infection.[29]

We have tried our best to compare and test the antibacterial efficacy of two homeopathic solutions with commercially available root canal medicament against the most resistant and stubborn bacteria E. faecalis. Despite our efforts, some limitations are present in the study which should be kept in mind during further trials on the same topic. First, this is an in vitro study that does not entirely simulate the oral environmental conditions. Second, various species of microflora are present in the root canal, but we have only concentrated on E. faecalis which limits its generalizability. Hence, further clinical trials should be conducted using polymicrobial flora of the root canal, and some other homeopathic medicine as the literature is limited regarding the use of homeopathic agents in endodontics.


   Conclusion Top


Although the complete sterilization of the root canal is not possible, efforts should be directed to reduce endodontic microorganisms to the minimum. In the present in vitro study, we have compared two homeopathic remedies with calcium hydroxide as intracanal medicament for disinfection of the root canal. The results of our study show that the homeopathic drugs have definite inhibitory activity against E. faecalis in a culture plate.

The ever-rising demand to disinfect the root canal and to tackle the problem of antibiotic resistance developed by microbes has encouraged us to seek alternatives. Homeopathy is one such alternative which demands more extensive studies and research so that the optimum utilization of the homeopathic drugs can be made in dentistry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Kurian B, Swapna DV, Nadig RR, Ranjini MA, Rashmi K, Bolar SR. Efficacy of calcium hydroxide, mushroom, and Aloe vera as an intracanal medicament against Enterococcus faecalis: An in vitro study. Endodontology 2016;28:137-42.  Back to cited text no. 17
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Correspondence Address:
Dr. Rahul Devenderlal Maria
Department of Conservative Dentistry and Endodontics, Bhabha College of Dental Sciences, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCD.JCD_515_20

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