|LETTER TO EDITOR
|Year : 2022 | Volume
| Issue : 3 | Page : 340-341
An evidence-based discussion on herbal-based root canal disinfection: A letter to editor unrevealing the current scope and future perspective
Kavalipurapu Venkata Teja1, Krishnamachari Janani2, Jerry Jose3, Galvin Sim Siang Liin4
1 Department of Conservative Dentistry and Endodontics, Mamata Institute of Dental Sciences, Bachupally, Hyderabad, Telangana, India
2 Department of Conservative Dentistry and Endodontics, SRM Dental College, SRM Institute of Science and Technology, Chennai, Tamil Nadu, India
3 Alwaye Dental Speciality and Implant Center, Aluva, Kerala, India
4 Department of Dental Materials, Faculty of Dentistry, Asian Institute of Medicine Science and Technology University, Kedah, Malaysia
|Date of Submission||28-Feb-2022|
|Date of Decision||25-Mar-2022|
|Date of Acceptance||26-Mar-2022|
|Date of Web Publication||1-Sep-2022|
Dr. Krishnamachari Janani
Department of Conservative Dentistry and Endodontics, SRM Dental College, SRM Institute of Science and Technology, Ramapuram, Chennai - 600 089, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Teja KV, Janani K, Jose J, Liin GS. An evidence-based discussion on herbal-based root canal disinfection: A letter to editor unrevealing the current scope and future perspective. Saudi Endod J 2022;12:340-1
|How to cite this URL:|
Teja KV, Janani K, Jose J, Liin GS. An evidence-based discussion on herbal-based root canal disinfection: A letter to editor unrevealing the current scope and future perspective. Saudi Endod J [serial online] 2022 [cited 2022 Sep 24];12:340-1. Available from: https://www.saudiendodj.com/text.asp?2022/12/3/340/354835
Root canal debridement is a collective combination of mechanical instrumentation with chemical disinfection using various root canal irrigating solutions. For an effective chemo-mechanical debridement, the claimed irrigating solutions should not only possess the antimicrobial property but also induce organic tissue dissolution. Over the past decade, extensive literature has been published on herbal-based disinfection focusing mainly on their antimicrobial activity, with very few studies focusing on inorganic smear removal. As far as organic tissue dissolution is concerned, to date literature proved the inefficiency of these herbal-based disinfectants in achieving the therapeutic effect. The reason quoted in multiple studies focusing on herbal irrigants claimed the antimicrobial resistance and cytotoxicity as two major reasons for this shift from conventional-based root canal disinfection. When critically analyzed, in an infected root canal system the contact time that the disinfecting solution have within the root canals is insufficient to cause higher antimicrobial resistance. To date, no reports are proving the conventional irrigating solutions as a major cause of the claimed antimicrobial resistance. Resistance is a broader term that needs to be critically evaluated. There are multiple host immune-based factors, which collectively play a major role along with the complexity of the root canal system, chronicity of the resident pathogen, and the virulence and tendency of genetic switching of the resistant pathogen leading to these therapeutic failures.
However ideally, when the collective data on failed cases are considered from the systematic reviews and meta-analysis, the data analysis revealed ineffective debridement of root canal space leaving the infected pulpal tissue or missed canals as a major cause for the failure. The concept of antimicrobial resistance had given false-positive assumptions to the researchers. When critically analyzed, the claimed antimicrobial resistance occurrence is hypothetical within the root canal system; in recent decades, there's been a huge trend change in endodontic literature, which shifted from the systemic to targeted local drug delivery. As far as the currently available literature is concerned, the studies evaluating the herbal-based disinfectants focused on assessing the antimicrobial efficiency either on single or two species rather than focusing on the complex biofilm level., Even the studies that tested on a single-species biofilm community also showed inferior results compared to the various concentrations of sodium hypochlorite. Hence, when the literature is collectively analyzed, the herbal-based irrigants may not eliminate biofilm either in primary infections, which could lead to a resistant species development leading to a high level of genetic alteration making eradication even more difficult during retreatment. A recent systematic review published by our colleagues also pointed out the inefficiency of herbal agents for root canal disinfection. Most of the included studies at in vitro level lacked standardization and yet showed inferior results which might not be clinically translated with the beneficial results.,
From a clinician's perspective, it is of utmost importance to render successful endodontic treatment with optimal disinfection of the root canal system with minimum contact time considering the patient's constraints. Invariably, herbal agents are way too far to achieve this. When the cytotoxicity of sodium hypochlorite is concerned, the claimed cytotoxicity always overrules the therapeutic advantage of the agent, which cannot be achieved by any herbal-based irrigants. When literature on cytotoxicity is critically assessed, the incidence of these events is considered to be the bare minimum with currently available passive root canal irrigation strategies and negative apical pressure root canal irrigant delivery systems. Hence, ideally, future research should focus more on altering the chemical composition using calcium hypochlorite formulations which are claimed to have less cytotoxicity even at higher concentrations. The current highest level of evidence claims the superiority of irrigant activating devices in achieving optimal debridement with conventional-based irrigating solutions. There is a lot of future scope on using laser-based disinfection and noninstrumentation endodontic concepts using GentleWave Technology in achieving the maximum root canal disinfection in minimally shaped canals. Hence, further research can strictly focus on evaluating the efficiency of irrigant activating devices in debriding the root canal system using minimal volumes and concentrations of sodium hypochlorite and also the alteration of techniques to further reduce the contact time and improve the treatment efficiency. Hence, when the final note on herbal-based disinfection is concerned, their inefficiency in self-sufficing the currently available gold standard irrigating solutions overrule their claimed benefits. Hence, we urge future research to be focused on assessing the multispecies biofilm, and also assessment on recent technologies achieving optimal debridement with minimal chairside treatment time.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Teja KV, Ramesh S. Shape optimal and clean more. Saudi Endod J 2019;9:235. [Full text]
Teja KV, Janani K, Srivastava KC, Shrivastava D, Jose J, Marya A, et al.
Comparison of herbal agents with sodium hypochlorite as root canal irrigant: A systematic review of in vitro
studies. Evid Based Complement Alternat Med 2021;2021:8967219.
Garg P, Tyagi SP, Sinha DJ, Singh UP, Malik V, Maccune ER. Comparison of antimicrobial efficacy of propolis, Morinda citrifolia, Azadirachta indica
, Triphala, green tea polyphenols and 5.25% sodium hypochlorite against Enterococcus fecalis
biofilm. Saudi Endod J 2014;4:122. [Full text]
Chhabra N, Gyanani H, Kamatagi L. Smear layer removal efficacy of combination of herbal extracts in two different ratios either alone or supplemented with sonic agitation: An in vitro
scanning electron microscope study. J Conserv Dent 2015;18:374-8.
] [Full text]
Shi Y, Deng Z, Yang Y, Cui L, Chen T, Hu M, et al.
Evaluation of sodium hypochlorite irrigant, bingpeng irrigant, and fufang bingpeng irrigant as endodontic irrigants during passive ultrasonic irrigation. Front Cell Infect Microbiol 2019;9:145.
Zehnder M, Belibasakis GN. On the dynamics of root canal infections-what we understand and what we don't. Virulence 2015;6:216-22.
Natanasabapathy V, Arul B, Santosh SS, Vasudevan A, Mahendran SS, Namasivayam A, et al
. Prevalence and morphology of root canal isthmus in human permanent teeth using micro-computed tomography: A systematic review. Saudi Endod J 2021;11:142. [Full text]
Güçlüer Ö. Human pulp tissue dissolution ability of different extracts of Sapindus mukorossi: An in vitro
study. Chin Herbal Med 2020;12:178-82.
Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal treatment: Systematic review of the literature – Part 2. Influence of clinical factors. Int Endod J 2008;41:6-31.
Narayanan S, Teja K, Ramesh S. Comparative evaluation of inter appointment pain and analgesic intake with calcium hydroxide and triple antibiotic paste as intracanal medicaments in patients with apical periodontitis – A randomized controlled single-blinded clinical trial. Braz Dent Sci 2021;24:1-11.
Gupta-Wadhwa A, Wadhwa J, Duhan J. Comparative evaluation of antimicrobial efficacy of three herbal irrigants in reducing intracanal E. faecalis
populations: An in vitro
study. J Clin Exp Dent 2016;8:e230-5.
Panchal V, Gurunathan D, Muralidharan NP. Comparison of antibacterial efficacy of cinnamon extract, neem extract as irrigant and sodium hypochlorite against Enterococcus fecalis
: An in vitro
study. Indian J Dent Res 2020;31:124-8.
] [Full text]
Prabhakar J, Senthilkumar M, Priya MS, Mahalakshmi K, Sehgal PK, Sukumaran VG. Evaluation of antimicrobial efficacy of herbal alternatives (Triphala and green tea polyphenols), MTAD, and 5% sodium hypochlorite against Enterococcus faecalis
biofilm formed on tooth substrate: An in vitro
study. J Endod 2010;36:83-6.
Divia AR, Nair MG, Varughese JM, Kurien S. A comparative evaluation of Morinda citrifolia
, green tea polyphenols, and Triphala with 5% sodium hypochlorite as an endodontic irrigant against Enterococcus faecalis
: An in vitro
study. Dent Res J (Isfahan) 2018;15:117-22.
Sharifian MR, Shokouhinejad N, Aligholi M, Emaneini M, Alizadeh J. Antibacterial substantivity of Carvacrol and sodium hypochlorite in infected bovine root dentin. Iran Endod J 2009;4:45-8.
Jose J, Palanivelu A, Subbaiyan H. Cytotoxicity evaluation of calcium hypochlorite and other commonly used root canal irrigants against human gingival fibroblast cells: An in vitro
evaluation. Dent Med Probl 2021;58:31-7.
Nagendrababu V, Jayaraman J, Suresh A, Kalyanasundaram S, Neelakantan P. Effectiveness of ultrasonically activated irrigation on root canal disinfection: A systematic review of in vitro
studies. Clin Oral Investig 2018;22:655-70.
Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of root canal debridement of human molars using the GentleWave system. J Endod 2015;41:1701-5.