Comparative evaluation of antimicrobial efficacy.12

Abstract

Background:
Microorganisms are the main cause of pulpal and periapical diseases. Hence, the elimination of such potential microbes is achieved by endodontic treatment. Mechanical preparation is the main mechanism to reduce the bacterial load in canals which is enhanced by intracanal irrigants. Despite these procedures, some bacteria might persist within the canals. It is important to disinfect the pulp space and dentinal tubules thoroughly with an effective endodontic irrigant to prevent reinfection of a treated root canal.

Aim:
This study aimed to evaluate and compare the antimicrobial efficacy of nanosilver (NS) Solution, Azadirachta indica, sodium hypochlorite, and normal saline when used as irrigants in infected root canals of primary teeth.

Settings and design:
The study was a prospective randomized control trial which was conducted as per the consort statement.

Materials and methods:
Eighty pulpally involved primary teeth requiring endodontic treatment of children aged 5-12 years were selected for this study. The subjects were randomly allocated to 4 groups (3 irrigant and control groups) consisting of 20 children each where Group I = NS solution, Group II = A. indica, Group III = Sodium hypochlorite (2.5%), and Group IV = Control group. Microbiological samples were collected at the baseline (before irrigation) and postirrigation after biomechanical preparation using the selected irrigant. The samples were subjected to an anaerobic bacterial culture test. Microbial colonies were identified and expressed as colony forming units per milliliter.

Statistical analysis:
Data were analyzed using one-way analysis of variance, Paired t-test, and Post hoc Bonferroni test.

Results:
NS solution showed the highest mean of 4.384 × 103 ± 1.019 followed by Sodium hypochlorite with a mean of 3.500 × 103 ± 1.193 and A. indica of 2.590 × 103 ± 0.778.

Conclusion:
Based on the results of this study, NS solution can be used as an alternative to other root canal irrigating solutions in primary teeth.

Full text

© 2023 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
76
ABSTRACT
Background: Microorganisms are the main cause
of pulpal and periapical diseases. Hence, the
elimination of such potential microbes is achieved
by endodontic treatment. Mechanical preparation
is the main mechanism to reduce the bacterial load
in canals which is enhanced by intracanal irrigants.
Despite these procedures, some bacteria might
persist within the canals. It is important to disinfect
the pulp space and dentinal tubules thoroughly
with an effective endodontic irrigant to prevent
reinfection of a treated root canal. Aim: This study
aimed to evaluate and compare the antimicrobial
efcacy of nanosilver (NS) Solution, Azadirachta
indica, sodium hypochlorite, and normal saline
when used as irrigants in infected root canals of
primary teeth. Settings and Design: The study
was a prospective randomized control trial which
was conducted as per the consort statement.
Materials and Methods: Eighty pulpally involved
primary teeth requiring endodontic treatment of
children aged 5–12 years were selected for this
study. The subjects were randomly allocated
to 4 groups (3 irrigant and control groups)
consisting of 20 children each where Group I = NS
solution, Group II = A. indica, Group III = Sodium
hypochlorite (2.5%), and Group IV = Control
group. Microbiological samples were collected at
the baseline (before irrigation) and postirrigation
after biomechanical preparation using the selected
irrigant. The samples were subjected to an anaerobic
bacterial culture test. Microbial colonies were
identied and expressed as colony forming units per
milliliter. Statistical Analysis: Data were analyzed
using one‑way analysis of variance, Paired t‑test,
and Post hoc Bonferroni test. Results: NS solution
showed the highest mean of 4.384 × 103 ± 1.019
followed by Sodium hypochlorite with a mean of
3.500 × 103 ± 1.193 and A. indica of 2.590 × 103 ± 0.778.
Conclusion: Based on the results of this study, NS
Comparative evaluation of antimicrobial efcacy
of nanosilver solution, Azadirachta indica, sodium
hypochlorite, and normal saline as root canal irrigants
in primary teeth
Zoya Tanvir, Zohra Jabin, Nidhi Agarwal, Ashish Anand, Nandita Waikhom
Department of Pediatric Dentistry, Institute of Dental Studies and Technologies, Ghaziabad, Uttar Pradesh, India
Introduction
Microorganisms are largely responsible for infection
in pulp leading to periapical diseases. The chances of
Address for correspondence:
Dr. Nidhi Agarwal,
Department of Pediatric Dentistry, Institute of Dental Studies
and Technologies, Ghaziabad, Uttar Pradesh, India.
E‑mail: doc.nagarwal@gmail.com
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How to cite this article:TanvirZ,JabinZ,AgarwalN,AnandA,
WaikhomN.Comparativeevaluationofantimicrobialecacyof
nanosilver solution, Azadirachta indica, sodium hypochlorite, and
normal saline as root canal irrigants in primary teeth. J Indian Soc
Pedod Prev Dent 2023;41:76-82.
Submitted: 14-Feb-2023 Revised: 21-Mar-2023
Accepted: 22-Mar-2023 Published: 01-Jun-2023
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of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
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Original Article
solution can be used as an alternative to other root
canal irrigating solutions in primary teeth.
KEYWORDS: Azadirachta indica, nanosilver, primary
teeth, root canal irrigants, sodium hypochlorite
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Tanvir, et al.: Antimicrobial ecacy of nanosilver solution, Azadirachta indica, sodium hypochlorite, and normal saline
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 41 | Issue 1 | January
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treatment success depend largely on the elimination
of infectious agents from the root canals before
obturation.[1]
This is accomplished by the procedure of root
canal treatment which includes the mechanical
instrumentation. It helps to debride infected canal
walls but it cannot eliminate bacteria from inaccessible
areas of root canal, resulting in inadequate removal
of bacteria. As a result of these limitations, irrigating
solutions have been developed to improve the
mechanical debridement procedure.[2,3] Hence, for
the complete elimination of infection, irrigation is an
important step for the success of root canal treatment.[4]
Literature is ooded with large numbers of studies
done on several irrigants which can be used at different
concentrations synergistically with mechanical root
canal cleaning methods.[2]
Every irrigant has some pros and cons but none of
these have been proven to accomplish the complete
bacterial elimination. Therefore, there is always an
ongoing search for a better irrigant.
The bacteria present in infected root canals include a
conned group of species which have been isolated
from periodontal pockets. The number of bacterial
species in root canals may vary from 1 to more than
12 whereas, the number of bacterial cells recovered are
between <102 and >108.[5]
A complex mix of obligate anaerobes and facultative
anaerobes is involved in the disease process of
dental abscesses.[6] Some bacteria are known as
periodontopathogens, including Prevotella intermedia,
Porphyromonas gingivalis, Tannerella forsythia, Eikenella
corrodens, and Fusobacterium nucleatum, Enterococcus
faecalis, Staphylococcus aureus have been closely
associated with acute symptoms of endodontic
infections, including abscesses Few studies that have
investigated the root canal microbiota of primary
teeth have suggested that the most commonly isolated
species in endodontic infections of primary teeth are
of Fusobacterium, Prevotella, and Porphyromonas genera.
Enterococcus species, Staphylococcus species.[7]
E. faecalis is a facultative anaerobic microorganism
which is a normal inhabitant of the oral ora. It has
the ability of dentinal tubule penetration and biolm
formation. It is most often related to the failure of
the root canal treatment and in several kinds of
periradicular lesions including primary and secondary
endodontic infections as it can survive in harsh
nutritional conditions.[4]
Nanosilver (NS) or Silver nanoparticles (AgNPs)
consist of nanosized structures formed from silver
atoms and range in diameter from 1 to 100 nm. At the
nanoscale, particles exhibit different physicochemical,
biological, and optical features. Their increased surface
area to volume ratio results in the increased reaction
between nanoparticles and target molecules in a very
short period.[2]
AgNPs are effective against several microorganisms
such as E. faecalis. They also have properties such
as high surface area, positive charge density, and
polycationic/polyanionic properties which enhance
their antibacterial effects.[3,4]
Currently, herbal medicaments are gaining popularity
owing to their minimal side effects and better
sustainability in nature. They are cost‑effective, have
better patient acceptance and also possess a sound
antimicrobial property that enhances the outcome of
the biomechanical procedures.[8]
Since time immemorial, Azadirachta indica commonly
known as neem has been used by ancient Indian people
as a cure for various diseases due to its therapeutic
properties.[9]
Its antibacterial, biocompatibility and antioxidant
qualities due to the presence of the isoprenoid
group (nimbin, nimbinin, nimbidinin, nimbolide and
nimbidic acid) make it an excellent endodontic irrigant.
Neem extract is efcient against Gram‑positive and
Gram‑negative bacteria, making it a viable option for
root canal irrigation.[10]
It is difcult to simulate the oral environment when
conducting trials in vitro conditions and the result
obtained may not be totally authentic. The literature
explored was lacking in such trials and documented
research available was done either in vitro or ex vivo.
Hence, there is a need of exploring in vivo trial of the
new emerging nanotechnology using NS solution as
root canal irrigant and thus the present study was
designed.
Over the time, as there has been an advancement from
conventional approach to the era of new irrigants for
improved treatment prognosis. The present study was
aimed at evaluating and comparing the antimicrobial
efcacy of NS Solution, A. indica, sodium hypochlorite
and normal saline when used as irrigants in infected
root canals of primary teeth.
Materials and Methods
The present study is a prospective randomized control
trial which was planned and conducted as per the
CONSORT statement (2010). The approval for this
study was taken from the ethics committee of the
institution. The selection of study participants was
done after screening 300 patients (5–12 years) visiting
the Outpatient Department of Pediatric and Preventive
Dentistry, IDST, The study included 80 children in
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Tanvir, et al.: Antimicrobial ecacy of nanosilver solution, Azadirachta indica, sodium hypochlorite, and normal saline
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 41 | Issue 1 | January
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total, both gender included, who satised the eligibility
requirements. Healthy children aged between 5 and 12
years, requiring endodontic treatment in primary teeth
with at least two‑third of total root length remaining
were included in the study as per the predetermined
eligibility criteria.
Medically compromised children and children with
any recent antibiotic exposure within the last 1 month
were excluded from the study.
The sample size was estimated considering the study
power at 80% with a condence interval of 5%. A total
of 80 subjects were included in the study against the
suggested sample of 60, to include a larger sample for
better statistical signicance using G*Power Version
3.1.9.4 (Franz Faul, Universitat Kiel, Germany).
Randomization was done by sequentially numbered,
opaque, and sealed envelopes method for allocation
concealment Based on the group assigned, the
appropriate irrigant was delivered in the canal. The
present study was a double‑blind clinical trial where the
participants and investigator were blinded regarding
the intervention type of irrigants administered to the
study subjects.
The selected samples were divided randomly into four
groups of 20 children each:
• Group I: NS solution group. A special formula
as prepared by Gonzalez‑Luna et al.[11] containing
nanosilver particles which were spherical and
particle size of 25 ± 6 nm was used
• Group II: A. indica group. An aqueous solution
of Neem extract was prepared by the method
described by Ambareen et al.[12]
• Group III: Commercially available Sodium
hypochlorite (2.5%) was used
• Group IV: Control group. Saline was used as a
control.
The synthesis of AgNPs in an aqueous solution was
carried out through chemical reaction of silver nitrate
and gallic acid with sodium bicarbonate as stabilizing
agent.
Characterization of the silver nanoparticles
The size and shape of the synthesized AgNPs were
analyzed using a JEOL JEM‑1230 TEM (Transmission
ElectronMicroscope). TEM images were obtained on
an FEI‑Tecnai G2 F20 at an accelerating voltage of 200
Kv. The analysis revealed that 99% of AgNPs were
spherical with a particle size of 25 ± 6 nm [Figure 1].
The procedure was performed by a single operator.
After local anesthesia, the rubber dam was placed.
A standard root canal access cavity preparation was
made with a high‑speed airrotor handpiece and a
round bur. On gaining the access, a sterile broach was
inserted for pulp extirpation.
On the same day, the working length was determined
radiographically using an RVG (woodpecker
Company) and a size #10 K‑le (Dentsply, Inc., MDCI
Ltd.) up to the apex of tooth.
Method of root canal sample collection
The sample collection was carried out two times for
each study subject, pre‑ and post‑irrigation.
Baseline sample was obtained by placing a sterile
paper point (Metabiomed, India) into the root canal le
1 mm short of working length into the canal for 30 s.
It was then immediately transported to the Eppendorf
tube containing 1 ml of nutrient broth (Hi Media
Laboratories Pvt. Ltd., India). The canals were gently
cleaned and shaped.
The root canal was alternatively irrigated with a total
of 0.5 mL of group‑specic irrigant, after every step of
instrumentation. A sterile 20 cc syringe with 28 gauge
needle (Dispo van) was used to deliver 0.5 mL of irrigant
into the canal Postirrigation sample was taken by placing
absorbent paper points into the canal till the apex per canal
of a size compatible with the root canal diameter were
sequentially placed for 30 s. They were then removed
from the canals and transferred directly into Eppendorf
tube containing 1 mL of nutrient broth with a sterilized
tweezer. The treated tooth was ushed with distilled
water to prevent the potential carryover of irrigants.
The collected sample Eppendorf tubes were stored
in an ice box chamber (4°C) and sent immediately to
a microbiological laboratory for microbial analysis.
Proper aseptic measures were followed at all steps.
Laboratory phase
Paper points were agitated in the vortex for 1 min.
to dislodge bacteria from paper points. The tube was
processed within 30 min of sample collection according
to the standard microbiological protocol where growth
was checked every 24 h for 48 h.
Figure 1: TEM image of Silver Nanoparticles used in the study
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Tanvir, et al.: Antimicrobial ecacy of nanosilver solution, Azadirachta indica, sodium hypochlorite, and normal saline
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 41 | Issue 1 | January
-Mar
ch 2023 | 79
The pre‑and post‑irrigation samples obtained were
incubated for 48 h at 37°C in an anaerobic chamber (85%
N2, 10% H2, 5% CO2).
After 48 h, the samples were cautiously taken out and
the growth on the plates was observed.
The colonies were identied by gram staining on
the basis of their morphology and visualized using
a stereomicroscope. The microbial colonies were
counted using digital colony counter. The baseline
and postirrigation microbial counts were expressed as
colonyforming units per milliliter.
Statistical analysis
Statistical analysis was performed using analysis of
variance, Paired t‑test, and Post hoc Bonferroni test.
The criteria for statistical signicance were dened as
P < 0.05.
Results
The anaerobic microorganisms were quantied in 80
primary teeth. A range of bacteria was identied and
isolated from the chosen primary teeth root canals,
including Enterococcus species, Staphylococcus species,
Bacillus species, and Candidal species.
It was seen that the mean bacterial colony counts of
all the isolated bacteria reduced considerably after
irrigation with all irrigants. A signicant difference
was seen in the postirrigation samples [Table 1].
Intergroup comparisons were done using the Post hoc
Bonferroni test, which showed a signicant difference
between Groups 1 and 2, Groups 1 and 4, Groups 2 and
3, Groups 2 and 4, and Groups 3 and 4. However, a
nonsignicant difference was seen when Group 1 was
compared to Group 3 [Table 2].
On comparison of all the four groups, Group 1 showed
the highest mean of 4.384 × 103 ± 1.019 followed by
Group 3 with mean of 3.500 × 103 ± 1.193 and Group 2
of 2.590 × 103 ± 0.778. The change in the microbial count
before and after irrigation was least in Group 4 with
the mean value of 0.825 × 103 ± 0.393 [Table 3].
Discussion
During endodontic procedures in permanent
teeth, various root canal irrigating solutions such
as sodium hypochlorite, chlorhexidine gluconate,
ethylenediaminetetraacetic acid, citric acid, and
hydrogen peroxide are recommended to achieve
complete debridement of canals. However, in their
primary counterpart’s nontoxicity to periapical tissues
is an important requirement of endodontic irrigants. In
primary teeth, overow of irrigating solution through
the apical region because of possible resorption areas
could damage the underlying periapical tissues.
Therefore, they should be used cautiously in the
primary dentition.[11]
In the present study, the three types of the irrigating
solutions (AgNPs, A. indica, and sodium hypochlorite),
showed potent antibacterial effects. There were
signicant differences observed between the three
experimental groups. Normal saline was used as a
control and it showed the least antimicrobial effect.
Silver ions possess long‑term antibacterial activity due
to sustained ion release and good biocompatibility
with human cells. With the advent of nanotechnology,
AgNPs have been synthesized, and they have shown
wide range of antimicrobial properties against various
bacteria, viruses, and fungi.[8] Hence, they were
selected for the present study. An irrigating solution
was prepared by incorporation of these nanoparticles
and was used in the study.
After attachment to the cell membrane and entrance
into the cell, nanoparticles interact with vital cell
components such as DNA and RNA and alter the cell
membrane permeability, genetic material, ribosomes,
and proteins producing reactive oxygen species
which alter the metabolic activity of bacteria. All of
these mechanisms result in cell lysis due to protein
denaturation.[4,13,14]
Previous studies have reported that particle size is
an important factor in the antimicrobial activity of
nanoparticles.[2] In the present study, NS solution of
spherical‑shaped particles was used due to their better
antimicrobial effect as stated in a study done by Hong
et al.[15]
It was suggested by Morones et al. that AgNps with a size
range of 1–100 nm have a great bactericidal potential
against both Gram‑positive and negative bacteria.[16]
In a study by Razumova et al., they demonstrated that
small particles of nanosilver of 1–2 nm could penetrate
the dentinal tubules.[17]
The present study was an in vivo study in contrast
to studies available in literature which are in vitro
or ex vivo. A particle size of 25.2 ± 6.5 nm of silver
nanoparticles was used. This size was in accordance
to a study by Chan et al. which is the one of the few
studies available in literature that investigated the
cytotoxic effects and biocompatibility to primary
human periodontal ligament stem cells. The particle
size used in the present study was safe and large
enough not penetrate dentinal tubules or periapical
area and cause damage.[18]
Keeping in view, the differences between the
in vitro (laboratory environment) and in vivo (oral
cavity) conditions, the present study used 25–30 ppm
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Tanvir, et al.: Antimicrobial ecacy of nanosilver solution, Azadirachta indica, sodium hypochlorite, and normal saline
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 41 | Issue 1 | January
-Mar
ch 2023 |
80
Table 1: Mean bacterial count among the different groups postirrigation
Groups Mean±SD SE Minimum Maximum P
Group 1: Nanosilver solution 1.931×103±0.731 0.163 1.20 3.40 0.0001
Group 2: A. indica group 3.345×103±0.978 0.218 1.20 5.40 0.0001
Group 3: Sodium hypochlorite 2.400×103±0.959 0.214 1.20 5.50 0.0001
Group 4: Normal saline 4.595×103±1.160 0.259 2.00 6.40 0.0001
One way ANOVA applied, F=29.421, P=0.0001 (signicant difference). SD=Standard deviation; SE=Standard error; A. indica=Azadirachta indica;
ANOVA=Analysis of variance
Table 2: Intergroup comparison postirrigation
Group (I) Group (J) Mean difference (I−J) Signicance 95% CI
Lower bound Upper bound
Group 1: Nanosilver solution Group 2: A. indica group −1.414 0.0001 −2.244 −0.583
Group 3: Sodium hypochlorite −0.469 0.781 −1.299 0.361
Group 4: Normal saline −2.664 0.0001 −3.494 −1.834
Group 2: A. indica group Group 3: Sodium hypochlorite 0.945 0.017 0.114 1.775
Group 4: Normal saline −1.250 0.001 −2.08 −0.419
Group 3 Group 4: Normal saline −2.195 0.001 −3.025 −1.364
Post hoc Bonferroni applied, P‑value signicant at P<0.05. CI=Condence interval; A. indica=Azadirachta indica
Table 3: Change in microbial count before and after irrigation
Groups Mean±SD (CFU/mL) SE 95% CI P
Lower bound Upper bound
Group 1: Nanosilver solution 4.384×103±1.019 0.227 3.906 4.861 0.0001
Group 2: A. indica group 2.590×103±0.778 0.174 2.226 2.954 0.0001
Group 3: Sodium hypochlorite 3.500×103±1.193 0.266 2.941 4.058 0.0001
Group 4: Normal saline 0.825×103±0.393 0.088 0.641 1.009 0.0001
Paired t‑test applied, P‑value signicant at P<0.05. SD=Standard deviation; SE=Standard error; CI=Condence interval; A. indica=Azadirachta indica; CFU/
mL=Colony forming units per milliliter
Table 4: Comparisons with the results of the previously published studies
Author Outcome measure Irrigants used Conclusion
Moghadas
et al.,[3]
To evaluate antimicrobial efcacy of root
canal irrigants
Nanosilver solution,
Sodium hypochlorite
Found no signicant difference
between NaOCl and the Nanosilver
solution in their in vitro study.
Luna P et al.[11] To determine the bactericidal effect of silver
nanoparticles as a nal irrigation agent in
endodontics.
Nanosilver solution,
Sodium hypochlorite
Bactericidal effect from the AgNPs
solution was same as that of sodium
hypochlorite at 2.25%
Moradi F,
Haghgoo R.[13]
To evaluate the antimicrobial effectiveness
against E. faecalis.
Nanosilver solution,
Sodium hypochlorite
Sodium hypochlorite to be more
effective against E. faecalis
NabavizadehM
et al.[19]
To investigate the antibacterial efcacy
against biolm E. faecalis using quantitative
real‑time polymerase chain reaction.
Nanosilver solution,
Sodium hypochlorite, Chlorhexidine
Nanosilver solution showed promising
results stating both to be equally
effective
Tyagi, et al.[20] To explore newer irrigation solutions to be
as effective as NaOCl.
Azadirachta indica, Morinda citrifolia,
Triphala, Green tea Polyphenols and
Sodium hypochlorite
Neem leaf extract can be used as
endodontic irrigant with an effective
antimicrobial property.
Podar R
et al., [21]
To evaluate and compare the antimicrobial
efcacy of root canal irrigants.
Sodium hypochlorite, Morinda
citrifolia, Azadirachta indica
Efciency of killing microorganisms
with 2.5% NaOCl solution was higher
in comparison with the experimental
groups
Ioannidis
et al.[26]
To examine the antimicrobial efcacy with
different irrigant delivery methods using a
novel ex vivo infected tooth model.
Nanosilver solution,
Sodium hypochlorite, chlorhexidine
gluconate, EDTA
The microbial killing efcacy of 2.5%
NaOCl was superior
Rodrigues
et al.[27]
To evaluate the antimicrobial action against
Enterococcus faecalis biolm and infected
dentinal tubules.
Nanosilver solution, Sodium
hypochlorite and Chlorhexidine
AgNP irrigant was not effective
compared to other used root canal
irrigants
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Tanvir, et al.: Antimicrobial ecacy of nanosilver solution, Azadirachta indica, sodium hypochlorite, and normal saline
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 41 | Issue 1 | January
-Mar
ch 2023 | 81
of NS solution that was similar to the formula by
Gonzalez‑Luna et al.[11]
In this study, the action of NS solution against microbes
was most effective, and a signicant reduction in the
microbial count was seen after its delivery into the root
canals. Table 4 shows comparisons with the results of
the some previously published studies alongwith their
conclusion.
Moghadas et al., and Nabavizadeh et al. also demonstrated
NS solution showing promising results as a root canal
irrigant in their study.[3,19] Moradi and Haghgoo in
their study also showed that AgNPs had antimicrobial
potential as a root canal irrigation solution for the
eradication of E. faecalis.[13]
In this study, A. indica also showed to be a good
antimicrobial irrigant, and signicant reduction in the
microbial count was seen after its delivery into the root
canals however, it was less efcacious as compared to
other irrigants used in the study.
The signicant reduction may be due to the presence
of the isoprenoid group of constituents of neem that
have a broad range of therapeutic and antimicrobial
effects. It also has anti‑adherence activity disturbing
the ability of the microorganism to colonize.
Literature shows A. indica to be an effective irrigant
when compared with other herbal irrigants. Garg
et al.,[20] Podar et al.,[21] Mustafa[22] Al Qarni and Fathy[23]
in their study also demonstrated similar results stating
that Neem leaf extract can be used as an endodontic
irrigant with an effective antimicrobial property. It
can be considered a benecial option in cases of low
infection as it does not cause any hypersensitivity or
discomfort.[20]
Sodium hypochlorite is still the most potent and widely
used irrigant in endodontic treatments. Therefore, in
the present study, for comparing the antimicrobial
efcacy of the new irrigant, it was selected as the gold
standard. The cytotoxicity of 5.25% NaOCl toward
periapical tissues has been stated; hence 2.5% NaOCI
was chosen as an appropriate concentration for
primary teeth root canal treatment.[24,25]
In the present study, Sodium hypochlorite showed to
be the second most effective antimicrobial irrigant.
Podar et al., Ioannidis et al. in their study reported
that the efciency of killing microorganisms with
2.5% NaOCl solution was higher in comparison with
the experimental groups.[21,26] The literature shows
various in vitro studies which are not in contrast with
the present study where both NS solution and Sodium
hypochlorite were equally effective as antimicrobial
irrigants. Gonzalez‑Luna et al., demonstrated in their
study that bactericidal effect from the AgNPs solution
as an endodontic irrigation with the same effect
occurred by using sodium hypochlorite at 2.25%.[11]
In addition, a study done by Moghadas et al. found
no signicant difference between NaOCl and the NS
solution in their in vitro study.[3]
The ndings of Ioannidis et al., Rodrigues et al.
are contradictory to the present study results and
they concluded that the AgNP irrigant was not
effective compared to other commonly used root
canal irrigants.[26,27] They used the AgNPs solution at
a concentration of 94 ppm in contrast to the present
study which used 25–30 ppm of NS solution.
The present study showed NS solution to be the
most effective antimicrobial irrigant for root canals of
primary teeth in comparison to the other three irrigants
used in the present study.
Conclusion
NS particles are effective in reducing the root canal
microbiota in primary teeth. Our principal nding
is that NS solution has a good bactericidal effect as
an irrigating solution in primary teeth. The gold
standard Sodium Hypochlorite often causes toxicity
in periapical tissues and often is avoided for primary
teeth. In such cases, NS solution can be considered as
a better alternative to other irrigants for primary teeth.
The present study is the rst documented in vivo
investigation using NS solution as a root canal irrigant.
More in vivo studies need to be done using a larger
sample size to potentiate the results obtained in the
present trial.
Limitations of the study
The study was done on 80 subjects. A larger sample
size is needed to potentiate the effects. Furthermore,
long‑term effects of NS solution need to be studied to
provide better scope for improvement in the present
study to achieve evidence.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conicts of interest.
References
1. Ruiz-Esparza CL, Garrocho-Rangel A, Gonzalez-Amaro AM,
Flores-Reyes H, Pozos-Guillen AJ. Reduction in bacterial
loading using 2% chlorhexidine gluconate as an irrigant in
pulpectomized primary teeth: A preliminary report. J Clin
Pediatr Dent 2011;35:265-70.
2. Lot M, Vosoughhosseini S, Ranjkesh B, Khani S,
Saghiri M, Zand V. Antimicrobial ecacy of nanosilver,
Downloaded from http://journals.lww.com/jped by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 06/01/2023

Tanvir, et al.: Antimicrobial ecacy of nanosilver solution, Azadirachta indica, sodium hypochlorite, and normal saline
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 41 | Issue 1 | January
-Mar
ch 2023 |
82
sodium hypochlorite and chlorhexidine gluconate against
Enterococcus faecalis. Afr J Biotechnol 2011;10:6799-803.
3. Moghadas L, Shahmoradi M, Narimani T. Antimicrobial
activity of a new nanobased endodontic irrigation solution: In
vitro study. Dent Hypotheses 2012;3:142-6.
4. FhhamB, HaidarA. Evaluation of the antibacterial ecacy
of silver nanoparticles as an irrigant against Enterococcus
faecalis – In vitro study. J Res Med Dent Sci 2019;7:21-7.
5. Sundqvist G. Ecology of the root canal ora. J Endod
1992;18:427-30.
6. Peter’s OA, Peters CI. Cleaning and shaping of the root canal
system. In: Hargreaves K, Cohen S, editors. Cohen’s Pathways
of Pulp. 10th ed. St. Louis.: Elsevier Mosby Publication; 2011.
p. 283-341.
7. Karkare SR, Ahire NP, Khedkar SU. Comparative evaluation
of antimicrobial activity of hydroalcoholic extract of Aloe
vera, garlic, and 5% sodium hypochlorite as root canal irrigants
against Enterococcus faecalis: An in vitro study. J Indian Soc
Pedod Prev Dent 2015;33:274-8.
8. Parwez AT, Prasanna PL, Bhargav MV, Balaji K, Hussain T.
Comparison of antimicrobial ecacy of herbal root canal
irrigants (Azadirachta indica, Morinda citrifolia) against
Enterococcus faecalis. World J Dent 2020;11:206-10.
9. AttavarSH.Anoverviewoftheantimicrobialeectofnatural
irrigants in disinfection of root canal system. Pharmacophore
2022;13:79-82.
10. Shah S, Venkataraghavan K, Choudhary P, Mohammad S,
Trivedi K, Shah SG. Evaluation of antimicrobial eect of
azadirachtinplantextract(Soluneem(™))oncommonlyfound
root canal pathogenic microorganisms (viz. Enterococcus
faecalis) in primary teeth: A microbiological study. J Indian
Soc Pedod Prev Dent 2016;34:210-6.
11. González‑LunaPI,Martínez‑CastañónGA,Zavala‑AlonsoNV,
Patiño-Marin N, Niño-Martínez N, Morán-Martínez J, et al.
Bactericideeect of silver nanoparticlesas a nalirrigation
agent in endodontics onenterococcus faecalis: Anex vivostudy.
Journal of Nanomaterials 2016;1–7.
12. Ambareen Z, Sapna K, Raj NS. Ecacy of herbal extracts.
J Oral Health Dent 2015;1:108-13.
13. MoradiF,HaghgooR.Evaluationofantimicrobialecacyof
nanosilver solution, sodium hypochlorite and normal saline
in root canal irrigation of primary teeth. Contemp Clin Dent
2018;9:S227-32.
14. de Almeida J, Cechella BC, Bernardi AV, de Lima Pimenta A,
Felippe WT. Eectiveness of nanoparticles solutions and
conventional endodontic irrigants against Enterococcus
faecalisbiolm.IndianJDentRes2018;29:347‑51.
15. Hong X, Wen J, Xiong X, Hu Y. Shape eect on the
antibacterial activity of silver nanoparticles synthesized
via a microwave-assisted method. Environ Sci Poll Res
2015;23:4489-97.
16. Morones JR, Elechiguerra JL, Camacho A, Holt K, Kouri JB,
Ramírez JT, et al.Thebactericidaleectofsilvernanoparticles.
Nanotechnology 2005;16:2346-53.
17. Razumova S, Brago A, Serebrov D, Barakat H, Kozlova Y,
Howijieh A, et al. The application of Nano silver argitos as a
nalrootcanalirrigationforthetreatmentofpulpitisandapical
periodontitis. In vitro study. Nanomaterials 2022;12:248.
18. Chan EL, Zhang C, Cheung GS. Cytotoxicity of a novel
nano – Silver particle endodontic irrigant. Clin Cosmet
Investig Dent 2015;7:65-74.
19. Nabavizadeh M, Abbaszadegan A, Gholam A. Antibiolm
ecacy of positively charged imidazolium‑based silver
nanoparticles in Enterococcus faecalis using quantitative
real-time PCR. Jundishapur J Microbiol 2017;10:e5561.
20. Garg P, Tyagi SP, Sinha DJ, Singh UP, Malik V, Maccune ER.
Comparison of antimicrobial ecacy of propolis, Morinda
citrifolia, Azadirachta indica, triphala, green tea polyphenols
and 5.25% sodium hypochlorite against Enterococcus fecalis
biolm.SaudiEndodJ2014;4:122‑7.
21. Podar R, Kulkarni GP, Dadu SS, Singh S, Singh SH. In vivo
antimicrobialecacyof6%Morinda citrifolia, Azadirachta
indica, and 3% sodium hypochlorite as root canal irrigants.
Eur J Dent 2015;9:529-34.
22. Mustafa M. Antibacterial ecacy of Neem (Azadirachta
indica) Extract against Enterococcus faecalis: An in vitro
Study. J Contemp Dent Pract 2016;17:791-4.
23. Fatimah M. Al Qarni, Fathy M. ElFasakhany, Laila M. Kenawi,
Asmaa M. et al. Antimicrobial activity of Azadirachta indica
(neem) and Salvadora persica (miswak) extracts as endodontic
irrigants. ENDO EPT 2019; 13:237-5.
24. Mohammadi Z, Shalavi S, Moeintaghavi A, Jafarzadeh H.
Areview over benets and drawbacks ofcombiningsodium
hypochlorite with other endodontic materials. Open Dent J
2017;11:661-9.
25. Kandaswamy D, Venkateshbabu N. Root canal irrigants.
J Conserv Dent 2010;13:256-64.
26. Ioannidis K, Niazi S, Mylonas P, Mannocci F, Deb S. The
synthesisofNanosilver‑grapheneoxidesystemanditsecacy
againstendodonticbiolms using a novel tooth model. Dent
Mater 2019;35:1614-29.
27. RodriguesCT,deAndradeFB,deVasconcelosLR,MidenaRZ,
Pereira TC, Kuga MC, et al. Antibacterial properties of silver
nanoparticles as a root canal irrigant against Enterococcus
faecalis biolm and infected dentinal tubules. Int Endod J
2018;51:901-11.
Downloaded from http://journals.lww.com/jped by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 06/01/2023