|Year : 2016 | Volume
| Issue : 2 | Page : 82-86
Association of endodontic signs and symptoms with root canal pathogens: A clinical comparative study
RV Vineet1, Moksha Nayak2, Subbannayya Kotigadde3
1 Department of Conservative Dentistry and Endodontics, Sree Mookambika Institute of Dental Sciences, Kulasekharam, Kanyakumari, Tamil Nadu, India
2 Department of Conservative Dentistry and Endodontics, KVG Dental College and Hospital, Karnataka, India
3 Department of Microbiology, KVG Medical College and Hospital, Sullia, Dakshin Kannad, Karnataka, India
|Date of Web Publication||18-Apr-2016|
R V Vineet
Department of Conservative Dentistry and Endodontics, Sree Mookambika Institute of Dental Sciences, Kulasekharam, Kanyakumari, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Objective: The purpose of this study was to evaluate the association of the common root canal pathogens namely; Streptococcus mitis and Enterococcus faecalis with specific endodontic signs and symptoms. Materials and Methods: Sixty subjects scheduled for endodontic treatment were divided into two groups comprising of 30 subjects with primary endodontic infections and 30 subjects with failed endodontic treatment. The endodontic signs and symptoms of the subjects were assessed using clinical and radiographic methods. Root canal samples were collected using sterile paper point. Advanced microbiological culture techniques were used to isolate S. mitis and E. faecalis from the root canal samples. The presence of root canal pathogens was then correlated with the corresponding endodontic signs and symptoms. Statistical analysis was done using Student's t-test and Fisher's exact test. Results: S. mitis was significantly associated with pain and periapical lesions in primary and retreatment cases (P = 0.04). E. faecalis had a strong correlation with tenderness on percussion in retreatment cases (P = 0.016). Conclusion: Association of S. mitis with pain and periapical lesion, as well as E. faecalis with tenderness on percussion, suggests a correlation between endodontic signs and symptoms with specific root canal bacterial species. Knowledge regarding the association of root canal pathogens and specific endodontic signs and symptoms could help in better understanding and a predictable therapeutic management of root canal infections.
Keywords: Endodontic signs and symptoms, Enterococcus faecalis, primary infection, retreatment cases, Streptococcus mitis
|How to cite this article:|
Vineet R V, Nayak M, Kotigadde S. Association of endodontic signs and symptoms with root canal pathogens: A clinical comparative study. Saudi Endod J 2016;6:82-6
|How to cite this URL:|
Vineet R V, Nayak M, Kotigadde S. Association of endodontic signs and symptoms with root canal pathogens: A clinical comparative study. Saudi Endod J [serial online] 2016 [cited 2019 Sep 19];6:82-6. Available from: http://www.saudiendodj.com/text.asp?2016/6/2/82/180621
| Introduction|| |
Root canal infection is a microbial infection of the tooth that is the most common cause for tooth pain. Knowledge of root canal pathogens and the inflammatory responses they elicit is a prerequisite to our understanding of the pathogenesis of root canal infections. Root canal infections are mostly accompanied by some clinical signs and symptoms such as pain, periapical lesion, tenderness to percussion, swelling, and sinus tract. These symptoms may be the consequence of the presence of bacterial irritants causing an inflammatory response of the periapical tissues. While many different bacterial species are able to colonize the dental root canals, it has been shown that there is a correlation between the presence of specific bacteria and some endodontic symptoms and signs.  Knowledge regarding the nature of endodontic microbiota depends upon the recognition of those microorganisms present in the root canal system of teeth with necrotic pulp and failed endodontic treatment. 
The literature on root canal infections shows that root canal harbors an array of microorganisms. However, based on the type of root canal infection and severity, the microorganisms isolated may also differ. Studies have shown that Streptococcus mitis and Enterococcus faecalis are the most prevalent microorganisms isolated from infected root canals.  Studies by Nayak et al. have shown that microorganisms can have a modulating effect on the inflammatory response of the body.  This suggests that based on the virulence and pathogenicity of microorganism present in the root canal system the clinical manifestations may also vary. Sanghavi et al. have demonstrated that there is an association of endodontic signs and symptoms with particular combinations of specific bacteria.  Hence, the purpose of the present investigation was to evaluate the association of S. mitis and E. faecalis with specific endodontic signs and symptoms.
| Materials and methods|| |
Subjects were selected from those who attended the Endodontic Clinical Section of KVG Dental College & Hospital (Sullia, Dakshin Kannad district, Karnataka, India) for root canal treatment or retreatment. The ethical clearance for the study protocol was obtained from Institutional Ethical Committee. The subjects were informed of the study protocol, and written consent was obtained before the sampling procedure was performed. Sixty patients requiring root canal treatment or retreatment were selected for the study and were divided into two groups:
Both males and females aged 20-70 years; immunocompetent subjects were included in the study. In Group 1, patients with a deep carious lesion involving pulp or with a diagnosis of pulpal necrosis were included. In Group 2, patients requiring retreatment of endodontically treated teeth with a diagnosis of apical periodontitis, root-filled teeth with radiographic evidence of periradicular disease and the termini of the root canal fillings at least 2 mm short of the radiographic apex were included in the study. Subjects with any systemic diseases, pregnancy and lactation, use of any antibiotics during past 3 months, immunocompromised patient, teeth that cannot be isolated with a rubber dam, calcified canals and teeth having periodontal pockets greater than 4 mm were excluded from the study.
- Group 1: 30 subjects with primary endodontic infections
- Group 2: 30 subjects with failed endodontic treatment requiring retreatment.
The following clinical features were recorded for each patient so that they could be correlated with the microbial findings: Tooth type, pain, tenderness to percussion, swelling, caries, sinus tract, and mobility. In primary infection, the clinical condition of pulp was evaluated by thermal stimuli and vitality tests. Radiographic examination of each tooth was done to evaluate for any pathosis, presence of caries or defective restoration, secondary caries and widening of periodontal ligament space. The size of the periapical lesion was calculated by taking the average of the lesion's largest dimension and the width perpendicular to the largest dimension.
Aseptic techniques were used throughout the root canal sampling procedure. The tooth was isolated with a rubber dam. All coronal restorations and carious lesions were completely removed. The tooth and surrounding field was rinsed using 30% hydrogen peroxide and then with 2.5% sodium hypochlorite solution for 30 s. The solution was inactivated with sterile 5% sodium thiosulfate. All instruments used for access cavity preparation were sterile. In the case of a treated canal, canal filling material was removed with the use of Gates Glidden drills and endodontic files without the use of any chemicals. Canal was rinsed with sterile saline to remove the remnants of filling material and debris, and to moisten the canal before sampling. Working length of the canal was determined radiographically using a 20 K-file 0.5 mm short of the radiographic working length. A small amount of sterile saline solution was placed into the root canal, and a sterile endodontic file was introduced to a level approximately 1 mm short of the tooth apex and a gentle filing motion was applied.
Sampling was performed by placing a sterile paper point in the canal to its full length for 60 s and was immediately placed in a transport medium containing 3 ml of sterile reduced transport fluid.
The root canal samples obtained were then immediately submitted to the microbiology section of our institution for culturing. The root canal samples were shaken in a vortex mixer for 60 s. After vortexing,
50 μl of sample was plated onto selective culture media. Mitis-Salivarius agar (Himedia) was used for S. mitis and Mac Conkey agar (Himedia) was used for E. faecalis. For culturing S. mitis a candle jar was used and incubated at 37°C for 5 days. The aerobic culturing technique was used for E. faecalis and incubated at 37°C for 2 days. After incubation, each plate was biochemically analyzed for growth and identification of bacteria using the colony morphology and Gram staining.
The data collected were typed onto a spreadsheet and statistically analyzed using SPSS 17.0 (SPSS Inc., Chicago, IL, USA). The results were statistically evaluated using Student's t-test and Fisher's exact test.
| Results|| |
The study population age ranged from 20 to 70 years. Primary infection (mean age = 36 years) and secondary infection (mean age = 32 years) groups included the equal proportion of men and women. Student's t-test showed no significant difference between the groups in terms of age distribution (P = 0.195). The clinical characteristics of the 60 teeth studied were as follows pain (40/60), tenderness on percussion (52/60), swelling (30/60), sinus tract (44/60), tooth mobility (11/60), and periapical radiolucency (60/60).
Microorganisms were recovered from all symptomatic teeth. The pain was noticed in 73.3%
(22 of 30 subjects) in primary infection and 60% (18 of 30) in secondary infection. Statistically significant association between pain and S. mitis was observed in primary infection (P = 0.04) by Fisher's Exact test [Table 1]. Tenderness on percussion was present in all cases from primary infection and 22 of 30 cases in secondary infection. E. faecalis accounted for 85.7% of cases associated with tenderness on percussion in secondary infection with the statistically significant association (P = 0.016) as evaluated by Fisher's Exact test [Table 2].
|Table 1: Association of S. mitis and E. faecalis with pain in primary and secondary infections |
Click here to view
|Table 2: Association of S. mitis and E. faecalis with tenderness on percussion in primary and secondary infections |
Click here to view
S. mitis was strongly associated with larger periapical radiolucency in both primary and secondary infection (P = 0.021) as shown in [Table 3].
|Table 3: Association of S. mitis and E. faecalis with periapical lesion size in both primary and secondary infections |
Click here to view
| Discussion|| |
In the present study, S. mitis was significantly associated with pain in primary infection. This is supported by the study of Luνsa et al. in which they also demonstrated a correlation between pain and Streptococcus sp.  S. mitis is a normal inhabitant of the oral cavity and possess an innate ability to attach to tooth surfaces by expressing specific proteins known as adhesins. Their cell wall contains peptidoglycans and lipoteichoic acids, which can influence inflammatory reactions and enhance the pain modulation. 
The current study showed that S. mitis was predominantly seen in periapical lesions of size >5 mm (77.8%). This supports the hypothesis that higher prevalence of microorganisms to larger lesions.  In infected root canals, surface attachment capacity may be of significance in the pathogenesis of apical periodontitis since Streptococcus sp. are found to invade dentinal tubules and morphological observations have indicated that microorganisms by releasing different extracellular proteins are able to adapt and survive in adverse environmental conditions.  Some of these proteins are key components in their metabolism, i.e., the discharge of formate-pyruvate lyase and lactose dehydrogenase produced under growth in low pH environment, or H + ATPase release in response to acid stress in the carious process. Thus, by means of these intrinsic regulations provoked by environmental changes, the survival of Streptococci in infected root canals can be explained. 
Although E. faecalis is found in most cases of infected canals, its role, if any, in the pathogenesis of the periapical diseases associated with necrotic pulp or endodontic failure, remains to be elucidated. In our study, there was a significant association between E. faecalis and tenderness to percussion (P = 0.016). However, most of the cases in the present investigation were diagnosed as asymptomatic apical periodontitis. Rocas et al. have also suggested that E. faecalis was more frequently detected in asymptomatic cases than in symptomatic ones using nested polymerase chain reaction analysis in which they detected E. faecalis in 11.5% of the asymptomatic teeth and in 3.7% of symptomatic cases. 
E. faecalis is found to be the most prevalent microorganism in root canals with persistent periapical lesions. This microorganism can even survive in an environment with scant available nutrients and in which commensality with other bacteria is minimal.  Studies by Pirani et al. have demonstrated that E. faecalis has the ability to penetrate dentinal tubules, sometimes to a deep extent, which can enable this species to escape the effects of intracanal antimicrobial procedures.  In addition, E. faecalis has been shown to be able to form biofilms in root canals, and this ability can be important for bacterial resistance and persistence after endodontic procedures.  E. faecalis is also resistant to calcium hydroxide, a commonly used intracanal medicament, and such ability to resist high pH values seems to be related to a functioning proton pump, which drives protons into the cell to acidify the cytoplasm. 
Environmental cues can also regulate gene expression in E. faecalis, affording this bacterium the ability to adapt to varying environmental conditions and, therefore, to survive in environments with a scarcity of nutrients and to resume growth when the nutrient source is restored. , Expression of virulence factors such as ace and esp which enable adherence to host tissue, modulation of host inflammatory response, and secretion of various products which enhance biofilm formation. 
There was no association for E. faecalis with a periapical lesion in the present study. There are some reports in the literature that have demonstrated that E. faecalis can also be found in root-filled teeth with no lesions.  Tronstad and Sunde investigated the occurrence of E. faecalis in different types of endodontic infections and reported the isolation of these bacteria in 24% of the root-filled teeth with lesions and in 18% of the root-filled teeth with no lesions.  Molander et al. examined the microbiological conditions of root filled teeth and isolated E. faecalis from 47% of the teeth with periradicular lesions and from 11% of the teeth without lesions.  More recently, Kaufman et al. detected E. faecalis in 6% of the root filled teeth with lesions and in 23% of the root filled teeth with no lesions.  In addition, some studies have not succeeded in detecting E. faecalis in root-filled teeth with lesions or have demonstrated that E. faecalis is not the dominant species in retreatment cases. , All of these reports along with viability aspects question the involvement of E. faecalis in causing endodontic failures. Is this species, actually participating in the causation of persistent periradicular diseases or is this species only present in the root canal because of its ability to survive in bleak environments like a treated root canal?
S. mitis and E. faecalis were not associated with other clinical features such as swelling, sinus tract, and mobility. This can be attributed to the findings of Gomes et al. that potential complex interactions of species resulting in characteristic clinical features cannot be achieved by individual species alone.  This study supports the previous studies by Gomes et al., Nayak et al. and Sanghavi et al. that there is an associations of endodontic signs and symptoms with specific endodontic pathogen or their combinations. ,, However, in this study, only two of the common root canal pathogens were included. Further research with more number of root canal pathogens and their association with endodontic signs and symptoms may help in comprehending the pathogenisis of root canal infection in a broader perspective.
| Conclusion|| |
There was a strong association between S. mitis and E. faecalis with specific endodontic signs and symptoms. The pain was associated with S. mitis in primary infections. There was a significant correlation between tenderness on percussion and E. faecalis in secondary infections. Association was noted between larger periapical lesion size (>5 mm) and S. mitis in primary and secondary infections. This suggests for further research in this field with different groups of root canal pathogens, which may be beneficial in grouping the root canal pathogens based on the corresponding endodontic signs and symptoms they are associated with. This will be helpful in categorizing the root canal pathogens into different complexes similar to those for periodontal infection, and such a strategy may improve the predictability of diagnosis and treatment of root canal infections.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gomes BP, Lilley JD, Drucker DB. Associations of endodontic symptoms and signs with particular combinations of specific bacteria. Int Endod J 1996;29:69-75.
Schirrmeister JF, Liebenow AL, Braun G, Wittmer A, Hellwig E, Al-Ahmad A. Detection and eradication of microorganisms in root-filled teeth associated with periradicular lesions: An in vivo
study. J Endod 2007;33:536-40.
Chávez de Paz L, Svensäter G, Dahlén G, Bergenholtz G. Streptococci from root canals in teeth with apical periodontitis receiving endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:232-41.
Nayak M, Kotigadde S, Shetty H, Vineet RV, Antony B. Impact of Peptostreptococcus
on type 2 diabetes mellitus related secondary root canal infections. Int J Pharm Sci Res 2013;4:4001-9.
Sanghavi TH, Shah N, Shah RR, Sanghavi A. Investigate the correlation between clinical sign and symptoms and the presence of P. gingivalis
, T. denticola
, and T. forsythia
individually or as a "Red complex" by a multiplex PCR method. J Conserv Dent 2014;17:555-60.
Guimaraes NL, Otoch HM, de Andrade LC, Ferreira CM, Rocha MM, Gomes FA. Microbiological evaluation of infected root canals and their correlation with pain. RSBO 2012;9:31-7.
Gomes BP, Pinheiro ET, Gadê-Neto CR, Sousa EL, Ferraz CC, Zaia AA, et al.
Microbiological examination of infected dental root canals. Oral Microbiol Immunol 2004;19:71-6.
Gajan EB, Aghazadeh M, Abashov R, Salem Milani A, Moosavi Z. Microbial flora of root canals of pulpally-infected teeth: Enterococcus faecalis
a prevalent species. J Dent Res Dent Clin Dent Prospects 2009;3:24-7.
Chavez LD. Gram positive organisms in endodontic infections. Endod Topics 2004;9:79-96.
Rôças IN, Siqueira JF Jr, Santos KR. Association of Enterococcus faecalis
with different forms of periradicular diseases. J Endod 2004;30:315-20.
Martina LP, Ebenezar AR, Ghani MF, Narayanan A, Sundaram M, Mohan AG. An in vitro
comparative antibacterial study of different concentrations of green tea extracts and 2% chlorhexidine on Enterococcus faecalis.
Saudi Endod J 2013;3:120-4.
Pirani C, Bertacci A, Cavrini F, Foschi F, Acquaviva GL, Prati C, et al.
Recovery of Enterococcus faecalis
in root canal lumen of patients with primary and secondary endodontic lesions. New Microbiol 2008;31:235-40.
Mindere A, Kundzina R, Nikolajeva V, Eze D, Petrina Z. Microflora of root filled teeth with apical periodontitis in Latvian patients. Stomatologija 2010;12:116-21.
Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Enterococcus faecalis
: Its role in root canal treatment failure and current concepts in retreatment. J Endod 2006;32:93-8.
Wang QQ, Zhang CF, Chu CH, Zhu XF. Prevalence of Enterococcus faecalis
in saliva and filled root canals of teeth associated with apical periodontitis. Int J Oral Sci 2012;4:19-23.
Siqueira JF Jr, Rôças IN, Souto R, de Uzeda M, Colombo AP. Actinomyces
species, streptococci, and Enterococcus faecalis
in primary root canal infections. J Endod 2002;28:168-72.
Kayaoglu G, Ørstavik D. Virulence factors of Enterococcus faecalis
: Relationship to endodontic disease. Crit Rev Oral Biol Med 2004;15:308-20.
Zoletti GO, Siqueira JF Jr, Santos KR. Identification of Enterococcus faecalis
in root-filled teeth with or without periradicular lesions by culture-dependent and-independent approaches. J Endod 2006;32:722-6.
Tronstad L, Sunde PT. The evolving new understanding of endodontic infections. Endod Topics 2003;6:57-77.
Molander A, Reit C, Dahlén G, Kvist T. Microbiological status of root-filled teeth with apical periodontitis. Int Endod J 1998;31:1-7.
Kaufman B, Spångberg L, Barry J, Fouad AF. Enterococcus
spp. in endodontically treated teeth with and without periradicular lesions. J Endod 2005;31:851-6.
Sassone LM, Fidel RA, Faveri M, Guerra R, Figueiredo L, Fidel SR, et al.
A microbiological profile of symptomatic teeth with primary endodontic infections. J Endod 2008;34:541-5.
[Table 1], [Table 2], [Table 3]