1

LNDCDCN1IC MICkC8ICLCG
ur. 8aef Sherlf
LecLure CuLllne
lnLroducLlon
orLals of enLry for mlcroorganlsms
Mlcroblal vlrulence and paLhogenlclLy
rlmary endodonLlc lnfecLlons
Mlcroblology of perlradlcular endodonLlc lnfecLlons
Mlcroblology of rooL canal fallures
LndodonLlc abscesses and cellullLls
ldenLlflcaLlon of bacLerla
Pow Lo combaL mlcrobes ln 8C1

Introduct|on

MosL of paLhologles of Lhe pulp and perlradlcular Llssues are dlrecLly

or lndlrecLly relaLed Lo mlcroorganlsms.1o be able Lo LreaL we have Lo
undersLand Lhe role of bacLerla ln endodonLlc paLhologles.
All Lhe surfaces of Lhe human body are colonlzed by mlcroorganlsms.
ColonlzaLlon ls Lhe esLabllshmenL of bacLerla ln a llvlng hosL. lL occurs lf
blochemlcal and physlcal condlLlons are avallable for growLh.
WhaL ls normal flora ?
ermanenL colonlzaLlon ln symbloLlc relaLlonshlp wlLh Lhe hosL Llssue resulL
ln esLabllshmenL of norma| f|ora.
When do normal flora cause dlsease ?
AlLhough Lhe mlcrobes ln Lhe normal oral flora parLlclpaLe ln many
lf Lhey galn beneflclal relaLlonshlps, Lhey are opporLunlsLlc paLhogens
Lo a normally sLerlle area of Lhe body such as Lhe denLal pulp or access
perlradlcular Llssues and produce dlsease.
When does lnfecLlon resulL ?
Infect|on resulLs lf:
- mlcroorganlsms damage Lhe hosL and
- produce cllnlcal slgns and sympLoms.
2
WhaL ls paLhogenlclLy ?
athogen|c|ty ls a Lerm used Lo descrlbe Lhe capaclLy of a mlcrobe Lo
produce dlsease,
WhaL ls v|ru|ence ?
1he degree of paLhogenlclLy produced by mlcroorganlsms ls called as
vlrulence.
orta|s of entry of m|croorgan|sms
1- Cpen cavlLy
2- Cpen denLlnal Lubules
3- erlodonLal llgamenL and glnglval sulcus
4- Anchoresls
3- laulLy resLaurLlons

1- Lntry through open cav|ty:
1hls ls Lhe mosL common way.
When enamel and denLln are lnLacL Lhey acL as barrlers Lo mlcroorganlsms.
When Lhey are desLroyed by carles, bacLerla galn enLry lnLo Lhe pulp.
1hls barrler mlghL also be desLroyed by: LraumaLlc ln[urles,
fracLures,cracks or resLoraLlve procedures, Lhus allowlng organlsms Lo enLer
Lhe pulp.
2- 1hrough dent|na| tubu|es:
Mlcroorganlsms can pass |nto Lhe denLlnal Lubules and subsequenLly Lo Lhe
pulp. 8acLerlal peoettotloo lnLo denLlnal Lubules ls greaLer ln LeeLh wlLh
necroLlc pulps. 8acLerla are preceded ln Lhe course of Lhe Lubules by
Lhelr breakdown producLs whlch may acL as pulp lrrlLanLs.
3: 1hrough the per|odonta| ||gament or the g|ng|va| su|cus:
Mlcroorganlsms also galn enLry vla accessory and laLeral canals whlch
connecL Lhe pulp and Lhe perlodonLlum.
lf perlodonLal dlsease or Lherapy desLroys Lhe proLecLlve coverlng, canal
may geL exposed Lo mlcroorganlsms presenL ln Lhe glnglval sulcus.
1he removal of cemenLum durlng perlo Lherapy also exposes denLlnal flulds
Lo oral flora.
3
: 4- Anachores|s
A LranslenL bacLeremla ls usually assoclaLed wlLh many acLlvlLles ln a
healLhy lndlvldual. Anachoresls refers Lo Lhe aLLracLlon of blood borne
bacLerla ln Lhe areas of lnflammaLlon. ln oLher words anachoresls ls a
process by whlch mlcroorganlsms are LransporLed ln Lhe blood Lo an
area of lnflammaLlon where Lhey esLabllsh lnfecLlon.
S- 1hrough fau|ty restorat|ons:
lL has been seen LhaL resLoraLlons wlLh marglnal leakage can resulL ln
conLamlnaLlon of Lhe pulp by bacLerla.
8acLerlal conLamlnaLlon of Lhe pulp can occur Lhrough:
- broken Lemporary seal,
- lnadequaLe flnal resLoraLlon and
- unused posL space.
M|crob|a| v|ru|ence & pathogen|c|ty
aLhogenlclLy ls Lhe ablllLy of mlcroorganlsms Lo produce a dlsease.
vlrulence ls Lhe degree of paLhogenlclLy
8acLerlal vlrulence facLors
1- Llpopolysacharldes
2- LxLracellualr veslcles
3- Lnzymes
4- laLLy aclds
3- olyamlnes
6- Capsule
7- llll
1- Llpopolysacharldes
1hese are presenL on Lhe surface of gram negaLlve bacLerla.
LS have nonspeclflc anLlgens whlch are neuLrallzed by anLlbodles. 1hey
exerL numerous blologlc funcLlons when released from cells ln Lhe form of
endoLoxlns. LndoLoxlns have capablllLy Lo dlffuse lnLo Lhe denLln.
varlous sLudles have shown Lhe relaLlonshlp beLween endoLoxlns and
perlaplcal lnflammLlon.

4
2- LxLracellular veslcles
1hese are produced by gram negaLlve bacLerla ln Lhe form of endoLoxlns,
ouLer membrane fragmenLs or blebs.1hey have Lrllamlnar sLrucLure
slmllar Lo ouLer membrane of Lhe parenL bacLerla. 1hese veslcles
conLaln varlous enzymes and Loxlc producLs whlch are responslble for
hemaggluLlnaLlon, hemolysls and bacLerlal adheslon. Slnce Lhey have
anLlgenlc properLles slmllar Lo parenL bacLerla, Lhey may proLecL
bacLerla by neuLrallzlng speclflc anLlbodles.

3- Lnzymes
Lnzymes produced by bacLerla have numerous acLlvlLles llke:
Lhey help ln spread of lnfecLlon,neuLrallzaLlon of lmmunoglobulln and Lhe
complemenL componenL.Mn leucocuLes release hydrolyLlc enzymes
whlch degeneraLe and lyse Lo form purulenL exudaLes and have
adverse effecLs on Lhe surroundlng Llssues.

4- laLLy aclds
varlous shorL chaln faLLy aclds llke proplonlc acld, buLyrlc acld are produced
by aneroblc bacLerla. 1hey cause neuLrophlllc chemoLaxls,
degranulaLlon, phagocyLosls, and sLlmulaLe lnLerleukln-1 producLlon
whlch furLher causes bone resorpLlon and perlradlcular dlsease.

3- polyamlnes
1hese are blologlcally acLlve chemlcals found ln Lhe lnfecLed canals.
Some of polyamlnes such as cadaverlne, puLresclne, spermldlne help ln
regulaLlon of Lhe cell growLh, regeneraLlon of Llssues and modulaLlon
of lnflammaLlon.
6- Capsules
CLher vlrulenL facLors llke capsules presenL ln gram negaLlve black
plgmenLed bacLerla, enable Lhem Lo avold phagocyLosls.

7- llll
llll may play an lmporLanL role ln aLLachmenL of bacLerla Lo surfaces and
lnLeracLlon wlLh oLher bacLerla.

3
M|crob|a| echosystem of the root cana|
Slnce many years, varlous researches have been publlshed regardlng Lhe
mlcroblal flora of Lhe rooL canals, normal and lnfecLed.
8uL over pasL 3-10 years, dlfference ln flora has been reporLed because of
lmproved Lechnology ln sampllng, culLurlng Lechnlques, culLure medla
as well as more advanced Lechnology regardlng lsolaLlon and
ldenLlflcaLlon of mlcroorganlsms.
MosL commonly gram poslLlve organlsms are found ln Lhe rooL canals,
buL gram negaLlve and obllgaLe anaerobes have been found ln rooL canals.
usuallay Lhe mlcrobes whlch can survlve ln envlronmenL of low oxygen
Lenslon are found ln rooL canals. usuallay Lhe mlcrobes whlch can
survlve ln envlronmenL of low oxygen Lenslon and can survlve Lhe
rlgors of llmlLed pabulums are found ln rooL canals.
varleLy of mlcroorganlsms enLer Lhe rooL canal sysLem Lhrough varlous
porLals of enLry buL only Lhose whlch flL for survlval ln such
envlronmenL do survlve.
1ypes of bacter|a |ns|de the root cana|
MosL commonly seen bacLerla ln rooL canals ls sLrepLococcl ,
oLhers can be:
sLaphylococcus,
gram negaLlve and
anaeroblc bacLerla.
8acLerlal mlx ln necroLlc pulps
ln necrot|c pu|p, a mlx of bacLerlal specles ls found.
necroLlc pulp space acLs as a reservolr
ln necroLlc pulp, Lhere ls:
- lack of clrculaLlon wlLh
- compromlsed hosL defense mechanlsm,
Lhls makes pulp as a reservolr for lnvadlng mlcrobes.

ln necroLlc pulps,
- Llssue flulds and dlslnLegraLed cells,
- low oxygen Lenslon and
- bacLerlal lnLeracLlons
are Lhe maln facLors whlch deLermlne whlch bacLerla wlll predomlnaLe.
6
1he growLh of one bacLerlal specles may be dependanL on Lhe oLher
bacLerlal specles whlch supplles Lhe essenLlal neuLrlenLs.ln Lhe slmllar
way anLagonlsLlc relaLlonshlp may occur ln bacLerla,
l.e. byproducLs of some bacLerlal specles may klll or reLard Lhe growLh of
oLher specles.
ln oLher words, some byproducLs can acL elLher as nuLrlenL or as Loxln
dependlng on bacLerlal specles.
We can summarlze Lhe followlng relaLlons beLween organlsms lsolaLed from
rooL canals:
1- mlxed lnfecLlons are more common Lhan slngle lnfecLlon.
2- ulp conLalns flora almosL slmllar Lo LhaL of Lhe oral cavlLy.
3- ApproxlmaLely 23 of lsolaLed organlsms are anaerobes.
4- Crganlsms lsolaLed from-flare-up cases as well as- asympLomaLlc cases
are almosL slmllar.
3- varlous researchers have ldenLlfled wlde varleLy of mlcroorganlsms ln
Lhe rooL canals whlch ls parLlally relaLed Lo personal lnLeresL and
culLure Lechnlques used by Lhem.
A rooL canal conLalnlng necroLlc pulp becomes a selecLlve hablLaL LhaL
allows some specles of bacLerla Lo grow ln preference Lo oLhers.
1he nuLrlenLs provlded by Lhe breakdown producLs of a necroLlc pulp,
Llssue fluld and serum from surroundlng Llssues along wlLh
low oxygen Lenslon, and bacLerlal by-producLs supporL Lhe growLh of
selecLed mlcroorganlsms.
1he coronal porLlon of a rooL canal may harbor organlsms dlfferenL from
Lhose ln Lhe aplcal porLlon.
Some specles of black-plgmenLed bacLerla, epLosLrepLococcl,
lusobacLerlum and AcLlnomyces specles have been found relaLed Lo
cllnlcal slgns and sympLoms.
8uL because of polymlcroblal naLure of Lhe endodonLlc lnfecLlons, no
absoluLe correlaLlon has been found beLween bacLerlal specles and
severlLy of endodonLlc lnfecLlons.
7
1he paLhogenlclLy of bacLerolds ls malnly relaLed Lo Lhe presence of
llpopolysacharldes and pepLldoglycans.
1hese :
1- lnduce hormones llke cyLoklnlns whlch play an lmporLanL role ln
lnflammaLlon.
2- SLlmulaLe 8-lymphocyLes.
3- AcLlvaLe compllmenL cascade.
4- Lnhance producLlon of varlous paln medlaLors llke bradyklnl, hlsLamlne,
and prosLaglandlns.
3- LS once released ( as endoLoxlns ) causes blologlcal effecLs lncludlng
lnflammaLlon and bone resorpLlon.
M|crob|o|ogy of per|rad|cu|ar endodont|c |nfect|ons
Cnce a necroLlc pulp ls lnfecLed, Lhe rooL canal sysLem becomes a
sLorehouse of mlcroorganlsms. AL Lhe aplcal foramen and aL Lhe rooL
ends of lnfecLed canal, plaque llke blofllms have been found.
LxLraradlcular bacLerla are usually assoclaLed wlLh
acuLe sympLoms, Lhe presence of a slnus LracL,
an lnfecLed cysL, or ln cases noL respondlng Lo endodonLlc LreaLmenL.
8oLh acuLe and chronlc perlradlcular abscesses are polymlcroblal lnfecLlons
wlLh large numbers of bacLerla.
erlaplcal lnflammaLory leslons conLaln macrophages, lymphocyLes, ( 1-cells
and 8-cells ), plasma cells and neuLrophlls. 1helr funcLlon ls Lo prevenL
mlcroorganlsms from lnvadlng perlradlcular Llssues.
8oLh Lhe pulp and perlradlcular lnflammaLory Llssues have been shown Lo
produce cellular and humoral responses Lo Lhe mlcroorganlsms.
WhaL does mlcroblal lnvaslon produce?
Mlcroblal lnvaslon of perlradlcular Llssues resulLs ln producLlon of an
abscess or cellullLls. whlch presenLs Lhe slgns and sympLoms because
of speclflc and non-speclflc lnflammaLlon.
SLudles have shown LhaL polymlcroblal lnfecLlons are found ln boLh acuLe
and chronlc sLages of perlradlcular lnfecLlons.ln many asympLomaLlc
paLlenLs wlLh chronlc lnfecLlon, slnus LracLs have also been found
lL has been seen LhaL slnus LracLs are assoclaLed wlLh chronlc perlradlcular
abscesses LhaL always encompass a polymlcroblal lnfecLlon.
8
1hey are relaLlvely asympLomaLlc because Lhe slnus LracL provldes a
paLhway for dralnage.
lnvaslon of perlradlcualr Llssues ls relaLed Lo Lhe vlrulence of Lhe
mlcroorganlsms and Lhe hosL's reslsLance.
erlaplcal lnflammaLory leslons are dynamlc lnflammaLory evenLs and may
conLaln an abscess wlLh bacLerla,- a cysL and surroundlng
lnflammaLory Llssue slmulLaneously.
lL ls seen LhaL Lhe mosL common cause of perslsLanL perlraldcular lnfecLlons
ls lncompleLe debrldemenL of Lhe rooL canal sysLem.
lmporLance of seallng . 1herefore a Lhree dlmenslonal seallng of Lhe
rooL canal sysLem ls necessary for resoluLlon of perlaplcal paLhologles.
M|crob||ogy of root cana| fa||ures
1he lack of perlradlcular heallng followlng rooL canal LreaLmenL seems Lo be
relaLed Lo Lhe perslsLence of mlcroorganlsms ln Lhe rooL canal sysLem.
1hls would appear Lo be relaLed Lo an lnablllLy Lo effecLlvely shape, clean,
and seal Lhe compleLe rooL canal sysLem.
8acter|a |n treated & untreated cases d|ffer
lnLeresLlngly, Lhe mlcroflora culLured from prevlously fllled rooL canals wlLh
perslsLenL aplcal leslons dlffer slgnlflcanLly from Lhe mlcrobes ln
unLreaLed necroLlc canals. 8esearches have shown LhaL mlcroblology of
unLreaLed canals ls dlfferenL from prevlously obLuraLed canals.
8acLerla lsolaLed from canals prevlously fllled buL sLlll assoclaLed wlLh
radlographlc leslons Lend Lo have more fuculLaLlve bacLerla raLher Lhan
sLrlcL anaerobes.
lnsLead of havlng approxlmaLely equal amounLs of gram-negaLlve gram-
poslLlve bacLerla, Lhe bacLerla lsolaLed from prevlously obLuraLed
- culLlvable sLralns of malnly gram one Lo Lwo canals Lend Lo have only
poslLlve bacLerla.
ln several sLudles, prevlously fllled canals had a relaLlve lncrease ln Lhe
presence of otetococcos foecolls.
9
1he presence of bacLerla ln all of Lhe falled rooL canals supporLs Lhe
asserLlon LhaL Lhe vasL ma[orlLy of endodonLlc LreaLmenL fallures are
caused by lnLraradlcular lnfecLlons.

1he exLenL of endodonLlc lnfecLlons beyond Lhe rooL canal sysLem ls relaLed
Lo:
- vlrulence of bacLerla,
- hosL reslsLance, and
- assoclaLed anaLomy.
lnfecLlons may locallze or conLlnue Lo spread.
An abscess ls a cavlLy of purulenL exudaLes conslsLlng prlmarlly of:
bacLerla,
bacLerlal byproducLs,
lnflammaLory cells,
lysed cells, and Lhelr conLenLs.

1he conLenL of lnflammaLory cells lncludes enzymes, whlch are damaglng Lo

Lhe surroundlng Llssues.
8acLerla ln an abscess are slmllar Lo bacLerla ln canals
LndodonLlc abscesses are polymlcroblal lnfecLlons wlLh organlsms slmllar Lo
Lhose found ln lnfecLed rooL canals.
A dlffuse cellullLls may have focl of abscesses.
lnduraLed swelllng. 1he spread of lnfecLlon and ensulng edema
assoclaLed wlLh lnflammaLlon ofLen produce an lnduraLed swelllng.
Cver Lhe Llme, neuLrophlls accumulaLe and produce a flucLuanL abscesses.
1hls concepL supporLs Lhe raLlonale for early lnclslon for dralnage Lo provlde
a paLhway for Lhe dralnage of bacLerla, bacLerlal by-producLs, and
lnflammaLory medlaLors.
10

Ident|f|cat|on of the bacter|a
Cu|ture
CulLure Laklng meLhod have done less Lhese days buL lL sLlll holds lLs
lmporLance because of wlde range of bacLerla found ln endodonLlc
lnfecLlons. 1he admlnlsLraLlon of anLlbloLlc may noL produce
saLlsfacLory resulLs, ln such cases, culLurlng may provlde a valuable
lnformaLlon for beLLer anLlbloLlc selecLlon.
1hus we can say LhaL wlLh supporLlve lnformaLlon from culLurlng, an
lnLelllgenL alLeraLlon ln anLlbloLlc Lherapy can be made.
now to combat m|crobes |n endodont|c therapy
1he mlcroblal echosysLem of an lnfecLed rooL canal sysLem and
lnflammaLory response caused by lL wlll perslsL unLll source of lrrlLaLlon
ls compleLely removed.
1he maln facLor whlch ls needed for succesful LreaLmenL of pulp and
perlradlcular lnflammaLlon ls compleLe removal of Lhe source of
lnfecLlon as mlcrobes and Lhelr byproducLs.
1- 1horough cleanlng and shaplng of Lhe rooL canal sysLem:
1horough cleanlng and shaplng followed by Lhree dlmenslonal pbLuraLlon
have been shown Lo produce compleLe heallng of perlradlcualr Llssues.
CompleLe debrldemenL of Lhe canal should be done wlLh Lhe use of lrrlganLs
llke sodlum hypochlorlLe whlch effecLlvely removes bacLerla as well as
Lhelr subsLraLe from lrregularlLles of canal sysLems where lnsLrumenLs
cannoL reach such as flns, lndenLaLlons, cul-de-sacs, eLc
Sodlum hypochlorlLe ls consldered an excellenL anLlmlcroblal agenL wlLh
Llssue dlssolvlng properLles.
lL can be used alone or wlLh oLher lrrlganLs llke chlorhexldlne, Lu1A,
hydrogen peroxlde, eLc.
: 2- CxygenaLlng a canal
Slmply by openlng lL ls deLrlmenLal Lo anaerobes.
use of oxygenaLed agenLs llke Clyoxlde can be of greaL help buL
care should be Laken Lo avold lnoculaLlon of Lhese oxygenaLlng agenLs lnLo
perlradlcular Llssues.
11

3- A LooLh wlLh serous or purulenL or hemorrhaglc exudaLe should be
allowed Lo draln wlLh rubber dam ln place for Llme under supervlslon.
An abscess whlch ls a poLenL lrrlLanL, has an elevaLed osmoLlc pressure.
1hls aLLracLs more Llssue fluld and Lhus more edema and paln.
uralnage Lhrough canal or Lhrough sofL Llssue decrease dlscomforL caused
by lnflammaLory medlaLors.
: 4- AnLlbloLlcs
Should also be consldered as ad[uncLlve ln severe lnfecLlons.
1he cholce of anLlbloLlc agenL should be done on Lhe knowledge of
mlcroorganlsms assoclaLed wlLh endodonLlc lnfecLlons.
pen|c||||n
1he drug of cholce for endodonLlc lnfecLlons ls penlclllln vk because of:
- lLs specLrum of mlcroblal acLlvlLy agalnsL mosL of bacLerla assoclaLed wlLh
endodonLlc lnfecLlons , and also
- because of lLs low LoxlclLy.
CLher anLlbloLlcs
CLher anLlbloLlcs whlch can be glven Lo combaL endo lnfecLlons lnclude:
amoxlclllln,
clarlLhromycln,
azyLhromycln, and
meLronldazol for Lhelr acLlon agalnsL mosL of Lhe anaerobes found ln rooL
canals.
A||ergy to pen|c||||n
lf Lhe paLlenL ls allerglc Lo penlclllln, cllndamycln ls recommended.
lL ls effecLlve agalnsL anaeroblc bacLerla, boLh obllgaLe as well as faculLaLlve.
: 3- lnLracanal medlcaLlons
1hese play an lmporLanL role ln combaLlng mlcrobes.
6- use of calclum hydroxlde ln canals wlLh necroLlc pulps:
1hls have been shown Lo provlde beneflclal resulLs.
1he use of calclum hydroxlde lnslde Lhe canal Lo lncreases:
- Lhe efflclency of sodlum hypochlorlLe and
- Lhe effecLlveness of anLlmlcroblal agenLs.
12

Calclum hydroxlde powder ls mlxed wlLh waLer or glycerln Lo from a Lhlck

pasLe whlch ls placed lnLo Lhe pulp chamber wlLh an amlgam carrler or
syrlnge.
1hls pasLe ls covered wlLh a sLerlle coLLon pelleL and access ls sealed wlLh
Lemporary.
1hus we can say LhaL for successful endodonLlc ouLcome , one musL have
awareness of Lhe close relaLlonshlp beLween endodonLlc lnfecLlons and
mlcroorganlsms.