Introduction

The initiation and perpetuation of pulpal and periapical diseases largely depend on the activity of
bacteria and their byproducts. Thus, effective elimination of microflora is a critical objective of
endodontic treatment. Among various treatment modalities, chemomechanical preparation is
considered a vital approach to reduce the bacterial load and promote the healing of periapical
tissues.(1)
Enterococcus faecalis is more likely to be found in failed cases than in primary infections (2),
and starvation increases the resistance of E. faecalis 1000-fold to 10,000-fold (3). It is probable
that the physiological state of cells, particularly in retreatment cases, is closest to the starvation
phase (4). Cleaning and shaping of the root canal reduced the bacterial population but did not
completely eliminate them. One possible reason for persistent endodontic infection may be the
retention of microorganisms in the dentinal tubules of the root canal (5). Hence, the use of an
intracanal medicament helps eliminate bacteria that remain even after cleaning and shaping,
thereby providing an environment conducive for periapical tissue repair (6). Nisin is a natural
antimicrobial peptide produced by lactic acid bacteria and is one of the most studied bacteriocin
so far [7]. Nisin can rapidly penetrate biofilms and form pores in the membrane cells [8]. It has
been proven effective against single-species biofilms of gram-positive organisms found in
catheters, wounds, and food [9]. Similarly, nisin has shown promising results against oral
pathogens [8], including those involved in root canal infections. Indeed, the high-purity form of
nisin (>95% purity) was found to be more potent than the low-content nisin (2.5% purity) against
multispecies oral biofilms [7].

Can be added to above –

Cleaning and shaping of the root canal system is crucial for the
success of root canal treatment. While shaping is primarily achieved
by the instrumentation process, cleaning is brought about by chemical
adjuncts in the form of irrigants and intracanal medicaments
8.Routine intracanal treatment procedures (biomechanical preparation)
may not adequately eliminate bacteria from the complex
anatomical features of the root canal system 10. In order to ensure
further reduction in microbiota, intracanal medicaments need to be
used between appointments.
The persistence of microorganisms may be considered the
primary cause of root canal failure. The ability of Enterococcus faecalis (E.faecalis) to penetrate into the dentinal tubules and
resist
bactericidal substances has been claimed to be the reason for this
organism to be implicated in persistent root canal infections.

Calcium hydroxide is one of the most commonly used

intracanal medicaments. Owing to the alkaline pH, this material
has a wide anti microbial spectrum 11 .However E.faecalis has been
shown to be resistant to the actions of calcium hydroxide 12 .This
has let to widespread research in endodontics looking for an alternative
intracanal medicament.

Chlorhexidine gluconate (2%) has been recommended as a

potential alternative to calcium hydroxide. This broad spectrum
antibacterial agent is able to destroy gram positive and gram negative
microbes. Metronidazole (2%) has been shown to be superior
to calcium hydroxide in inhibiting E.faecalis 13
Natural remedies are
increasingly finding their way into endodontic treatment with agents
like Morinda citrofolia 7, triphala 8, curcumin 9 and propolis 10 being
evaluated as irrigants and intracanal medicaments. Curcumin (diferuloylmethane),
the main yellow bioactive component of turmeric
has a wide spectrum of biological actions, including antimicrobial,
anti-inflammatory and antioxidant activities

Propolis is basically
composed of flavonoids, phenolics and aromatic compounds

similarly nisin

1) Siqueira JF, de Uzeda M: Intracanal medicaments: evaluation of the antibacterial effects of chlorhexidine,
metronidazole, and calcium hydroxide associated with three vehicles. J Endod. 1997, 23:167-9.
10.1016/S0099-2399(97)80268-3

2) Sirén EK, Haapasalo MPP, Ranta K, Salmi P, Kerosuo ENJ. Microbiological findings
and clinical treatment procedures in endodontic cases selected for microbiological
investigation. Int Endod J 1997;30:90 –5.
3. Portenier I, Waltimo T, Ø=rstavik D, Haapasalo M. The susceptibility of starved
stationary phase, and growing cells of Enterococcus faecalis to endodontic medicaments.
J Endod 2005;31:380 –5.
4. Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Enterococcus faecalis: its role in root
canal treatment failure and current concepts in retreatment. J Endod 2005;32:93– 8.

5. Safavi KE, Spångberg SW, Langeland K. Root canal dentinal tubule disinfection.
J Endod 1990;16:207–10.
6. Chong BS, Pittford TR. The role of intracanal medication in root canal treatment. Int
Endod J 1992;25:97–106.

7. Shin, J.M.; Ateia, I.; Paulus, J.R.; Liu, H.; Fenno, J.C.; Rickard, A.H.; Kapila, Y.L. Antimicrobial nisin acts against saliva
derived
multi-species biofilms without cytotoxicity to human oral cells. Front. Microbiol. 2015, 6, 617.

8. Davison, W.M.; Pitts, B.; Stewart, P.S. Spatial and temporal patterns of biocide action against Staphylococcus epidermidis
biofilms.Antimicrob. Agents Chemother. 2010, 54, 2920–2927.

9. Okuda, K.; Zendo, T.; Sugimoto, S.; Iwase, T.; Tajima, A.; Yamada, S.; Sonomoto, K.; Mizunoet, Y. Effects of bacteriocins on
methicillin-resistant Staphylococcus aureus biofilm. Antimicrob. Agents Chemother. 2013, 57, 5572–5579.

10. Vianna ME, Horz HP, Conrads G, Zaia AA, Souza-Filho FJ, Gomez BP.
Effect of root canal procedures on endotoxin and endodontic pathogens.
Oral Microbiol Immunol; 22: 411-418. 2007.

11. Siqueira JF Jr, Lopes HP. Mechanisms of antimicrobial activity of calcium

hydroxide: a critical review. Int Endod J; 32: 361-369. 1999.

12 . George S, Kishen A, Song KP. The role of environmental changes on

monospecies biofilm formation on root canal wall by E.faecalis. J Endod;
31:867-872. 2005.

13. Krithikadatta J, Indira R, Dorothy Kalyani AL. Disinfection of dentinal

tubules with 2% chlorhexidine, 2% metronidazole, bioactive glass when
compared with calcium hydroxide as intracanal medicaments. J Endod;
33: 1473-1476. 2007.

Traditionally calcium hydroxide has been the

choice as an intracanal medicament, because of its
wide spectrum of action against many endodontic
pathogens, which is thought to be mainly due to its
high alkalinity causing destruction of bacterial cell
membrane (6). One of the identifying features of
E.faecalis is that it withstands the high alkalinity and so
resistant to calcium hydroxide dressing.

Nisin, a naturally occurring antimicrobial

peptide, produced by Streptococcus lactis sub species
lactis. It has antimicrobial activity against a wide range
of Gram-positive bacteria and their spores (8); even
against drug resistant E.faecalis isolates (9). Its use in
dentistry has so far been limited. Recently it was found
to be effective in the elimination of E.faecalis from with
in the root canal system.