COMPARATIVE EVALUATION OF ANTIMICROBIAL EFFICACY OF TRIPLE ANTIBIOTIC PASTE AND MODIFIED DOUBLE ANTIBIOTIC PASTE USING DIFFERENT VEHICLES AGAINST CANDIDA ALBICANS

Dr. Urvashi Ojha Tiwari, Dr. Afsana Begum, Dr. Jyoti Jain, Dr. Sandhya Yadav and Dr. Nurez Anwar ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 25 November 2019 Final Accepted: 27 December 2019 Published: January 2020

Endodontic infections are inherently polymicrobial in nature. These microorganisms flourish in harmonious consortium. No single microorganism can be held responsible for the failure of endodontic treatment or persistent apical periodontitis.The vivid flora involved in such incidences includes bacteria as well as fungi. Amongst the fungi Candida sp., Aspergillus sp ,Penicillium sp. are the common ones to be isolated. Several studies have reported higher frequency of candida albicans in cultures from root canals of teeth of failed endodontic treatment. Though chemomechanical preparation of root canal eliminates most of the microbes, complete sterility of root canals is difficult to achieve. Intracanal medicaments come into play in such situations. The triple antibiotic paste is most widely used intracanal medicament in present-day. This study evaluated the antimicrobial activity of triple antibiotic and modified double antibiotic paste with different vehicles against C.albicans. The antimicrobial efficacy was evaluated by using agar well diffusion method. Medicaments were placed in wells on agar plates previously inoculated with C.albicans. All plates were incubated and the diameter of bacterial inhibition zones on agar plate was measured in millimeters at 24, 48 and 72 hours at 37°C and 100% humidity. Result showed that Triple antibiotic paste was better than double antibiotic paste. TAP + CHX =TAP + chitosan > DAP +CHX > DAP + chitosan. Triple antibiotic paste (TAP) with chlorhexidine and TAP with chitosan had equal effectiveness, and Modified Double antibiotic paste (DAP) with chlorhexidine had better efficacy than DAP with chitosan.

Introduction:-
Endodontic infections are characteristically polymicrobial in nature. These microorganisms flourish in harmonious consortium. No single microorganism can be held responsible for the failure of endodontic treatment or persistent apical periodontitis.
The vivid flora involved in such incidences includes bacteria as well as fungi. Amongst the fungi Candida sp., Aspergillus sp ,Penicillium sp. are the common ones to be isolated. Several studies have reported higher frequency of candida albicans in cultures from root canals of teeth of failed endodontic treatment. Though chemomechanical preparation of root canal eliminates most of the microbes, but complete sterility of root canals is difficult to achieve.

ISSN: 2320-5407
Int. J. Adv. Res. 8(01), 528-533 529 These microbes require antimicrobial agents. Systemic application of antimicrobial agents has its own adversities, the infected root canal is not accessible to the local immune system and hence the amount of drug reaching canal space is minimal and unlikely to inhibit the bacterial growth, this incompetence of systemic antibiotics in endodontic conditions has resulted in the use of local application of antimicrobial in root canal treatment. (1,2) Intracanal medicaments come into play in such situations. Polyantibiotic paste containing penicillin, bacitracin, streptomycin and caprylate sodium is the first reported locally used antimicrobial intracanal medicament. (3) Considering the polymicrobial nature of endodontic infections, tetracyclines, a group of broad-spectrum antibiotics that are effective against a wide range of microorganisms, was proposed as intracanal topical antibiotics.
A conceptual swing has occurred from conventional to broad-spectrum treatment and now to combination modality due to vast variety of microorganisms encountered in the root canals. There have been studies on effectiveness of calcium hydroxide, chlorhexidine, fluconazole, chitosan, triple antibiotic paste etc. against E.feacalis and C.albicans.
Triple antibiotic paste is the most successfully and widely used intracanal medicament in present-day. Triple antibiotic paste (TAP), that was 1 st used by Hoshino E et.al in 1996 ,is a mixture of metronidazole, ciprofloxacin, and minocycline.It has proven its effectiveness against E. faecalis and so is widely used .Since the endodontic infections are polymicrobial effectiveness of any intracanal medicament against single microrganisms does not makes it best choice To increase the stability of intracanal medicament, chitosan is used as a drug carrier. It has drawn attention of dental researchers due to its biocompatibility, biodegradability ,bioadhesion and lack of toxicity,it has additional advantage of slow and controlled release of intracanal medicament. (4,5,6) It is produced by the partial deacetalylation of chitin which is a natural polysaccharide composed of β (1→4) linked N-acetyl glucosamine units. Chitosan derived from the exoskeleton of crustaceans (such as crabs) & is a cationic polymer. Its important property ,to be used as excipient is because of its ability to become hydrated and form gels in acidic aqueous environments and is thus used to prepare slow release drug delivery systems.
Chlorhexidine (CHX) is known for its broad-spectrum antimicrobial and high substantivity. Efficacy of Chlorhexidine is because of the interaction of this cationic molecule with the anionic phosphate groups on the microbial cell wall. Which results in shifting of osmotic equilibrium of the cell and increased permeability of cell wall which allows the Chlorhexidine molecule to penetrate the bacteria.
Adding a vehicle to the intracanal medicaments not only improves the handling characteristics, but also improves antimicrobial activity, enhances diffusion through dentinal tubules and release of the medicaments. (6,7) The present study was designed to evaluate the antimicrobial activity of triple antibiotic and modified double antibiotic paste with chlorhexidine and chitosan as vehicles against C.albicans. The ciprofloxacin, metronidazole, and minocycline powders thus obtained were weighed separately and mixed in a 1:1:1 proportions, respectively, to obtain TA mixture.

Materials And
The crushed powder was passed through a fine sieve to remove heavy filler particles and obtain a fine powder.

Preparation of the medium for Candida albicans:
C. albicans (ATCC 10231) strain was used in this study. Cultures were maintained on Sabouraud Dextrose Agar (SDA, Sigma-Aldrich, USA) slants in stock cultures. Stock cultures were subcultured onto freshly prepared SDA plates and incubated at 35ºC for 48 hours. Growths from freshly subcultured isolates were suspended in 10ml of sterile saline to obtain a turbidity of 0.5 McFarland standard(equivalent to 1.5x10 8 CFU/ml. Aliquots of the suspension containing C . albicans were spread on 10 different (9)140-mm diameter Petri dishes containing Mueller-Hinton Agar medium (Merck, Darmstadt, Germany). Excess inoculum was removed with a pipette and the inoculated plates were dried for 15 minutes at 37°C. Each plate was divided evenly into 4 sections. In each section of each plate, a well of dimension 5 mm in diameter and 4 mm in depth was created with a sterile stainless steel cylinder. Each medicament prepared was placed in one well each. ( Figure 1) All plates were incubated at 37°C under aerobic conditions, and zones of growth inhibition were measured at 24, 48, 72 hours using a plastic ruler and was recorded for each material. All statistical analyses were performed with the SPSS (  Overall, group A1 had the largest zones of growth inhibition at all time intervals when compared to other group.  Our results indicate that all the medicaments resulted in decline of microbial growth which was evident after measuring zone of inhibition. Group A1 (TAP-CHX group) was significantly more effective at killing C. albicans than TAP-chitosan. Thus combining chitosan with TAP could not prove its efficacy over TAP CHX combination in eradicating C. albicans. Furthermore unlike against E.faecalis, (12) triple antibiotic remains superior choice against C. albicans over DAP.

Conflict of interest:
Authors declare that there is no conflict of interest.

Conclusion:-
For obtaining maximum clinical benefits of the anti-microbial agents as intracanal medicaments, further research should be conducted to investigate the best drug delivery form, substantivity and the drug combinations. No single combination of drugs if effective against all microbes. Thus choosing intracanal medicament in each case is a serious task and should be cautiously carried out to obtain maximum benefit without giving rise to resistant strains.