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ORIGINAL ARTICLE
Year : 2020  |  Volume : 38  |  Issue : 4  |  Page : 361-366
 

Comparative evaluation of antibacterial efficacy of conventional glass-ionomer cement and bulk-fill alkasite material when combined with doxycycline and double antibiotic paste containing ciprofloxacin and metronidazole against Streptococcus mutans and Lactobacillus spp.: An in vitro study


Department of Pedodontics and Preventive Dentistry, KAHER'S KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India

Date of Submission21-Mar-2020
Date of Decision11-Aug-2020
Date of Acceptance01-Dec-2020
Date of Web Publication5-Jan-2021

Correspondence Address:
Dr. Niraj S Gokhale
Department of Pedodontics and Preventive Dentistry, KAHER'S KLE VK Institute of Dental Sciences, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_143_20

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   Abstract 


Introduction: Glass-ionomer cement (GIC) have been indispensable to pediatric dentistry. Along with these, newer materials like bulk-fill alkasite cement (Cention N) are popularizing. In spite of this, the search is still on for the “ideal” bioactive material which could provide a therapeutic edge. In light of this, incorporation of antibiotics in GIC or newer materials like bulk-fill alkasite cement (Cention N) would provide a novel alternative material to the dentists. Aim: The study was aimed at comparing the antibacterial efficacy of conventional glass-ionomer cement (CGIC) and bulk-fill alkasite cement (Cention N) with doxycycline (DOX) and double antibiotic paste (DAP) containing metronidazole and ciprofloxacin (1.5% w/w) on Streptococcus mutans and Lactobacillus. Materials and Methods: Agar well diffusion method was followed, in which material discs of 10 mm were made and inserted into the wells. Inhibition zones were calculated after incubation for 24 h at 37°C with zone interpretation scale. Results: A highly significant statistical correlation was found between antibacterial efficacy of the control groups (CGIC and bulk-fill alkasite cement [Cention N]) without antibiotics as compared to the experimental group (CGIC and bulk-fill alkasite cement [Cention N] with DOX and DAP), P = 0.0001 and P = 0.0006 for the CGIC group and P = 0.0147 and P = 0.0080 for the Cention N group (P < 0.05). Conclusion: Incorporation of antibiotics significantly enhanced the antibacterial efficacy of CGIC and bulk-fill alkasite cement (Cention N).


Keywords: Antibacterial efficacy, bulk-fill alkasite cement, double antibiotic paste, doxycycline, glass-ionomer cement


How to cite this article:
Joshi RS, Gokhale NS, Hugar SM, Soneta SP, Badakar CM, Patil VH. Comparative evaluation of antibacterial efficacy of conventional glass-ionomer cement and bulk-fill alkasite material when combined with doxycycline and double antibiotic paste containing ciprofloxacin and metronidazole against Streptococcus mutans and Lactobacillus spp.: An in vitro study. J Indian Soc Pedod Prev Dent 2020;38:361-6

How to cite this URL:
Joshi RS, Gokhale NS, Hugar SM, Soneta SP, Badakar CM, Patil VH. Comparative evaluation of antibacterial efficacy of conventional glass-ionomer cement and bulk-fill alkasite material when combined with doxycycline and double antibiotic paste containing ciprofloxacin and metronidazole against Streptococcus mutans and Lactobacillus spp.: An in vitro study. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2021 Apr 18];38:361-6. Available from: https://www.jisppd.com/text.asp?2020/38/4/361/306212





   Introduction Top


Dental caries is the most prevalent disease all over the world. The burden of dental caries for both developed and developing countries has been almost 5%–10% of total health-care budget, which is seen to be more than the cost incurred for treating cardiovascular diseases.[1] Moreover, due to high cost of treatment, the incidence of untreated dental caries in children is seen to be substantial in developing countries. Not only does this disease cause a huge financial burden if not treated adequately but also decreases the overall health-related quality of life in the pediatric population.[2]

There has been an evolution of dental materials used to treat caries since the 1900s. Glass-ionomer cement (GIC) were used since the 1970s in primary as well as permanent dentition as restorative cement. They were first described by Alan Wilson and Brian Kent.[3] This material is popular due to its cariostatic action, mainly due to its fluoride-releasing property. It also has minimal cavity preparation, unlike amalgam due to its chemical bonding to tooth structure. The disadvantages of this material include poor mechanical properties, low stress-bearing capacity, and inferior esthetics. Due to this, GIC since its early days is evolving. Although conventional glass-ionomer cement (CGIC) are still rampantly used, better materials such as composites and compomers are also providing an alternative to GIC.

Composites became popular during the 1980s, resin-modified glass ionomers and compomers were introduced in the 1990s, and the latest materials on the rise are bulk-fill composites.[4],[5],[6] Cention N is a newer bulk-fill “alkasite” restorative material, which is essentially a subgroup of the composite material class. It has the property of releasing fluoride, calcium, and hydroxide ions and can be self-cured as well as light cured. This material caused less polymerization shrinkage as compared to composite and hence is a newer, better restorative material.[7]

It is a known fact that the antibacterial treatment of dentin reduces the overall bacterial load of the cavity.[8] The property of treating infections locally is an interesting notion. Although many synthetic as well as herbal materials have been added to GIC to increase its overall antibacterial efficacy, antibiotics are the most reliable. Antibiotics such as doxycycline (DOX) and double antibiotic pastes (DAPs) have been used in dentistry for many years. They inhibit the growth of microorganisms by acting on their cellular structures. The purpose of our study is to analyze the antibacterial efficacy of CGIC and bulk-fill alkasite cement against  Streptococcus mutans Scientific Name Search obacillus spp. independently and in combination with DOX and DAP for determination of relative antibacterial efficacy.


   Materials and Methods Top


Preparation of material

In this study, a CGIC (Fuji 2 GIC) and a bulk-fill alkasite cement (Cention N) were used as controls. In the experimental group, two groups of antibiotics, DAP containing metronidazole and ciprofloxacin and DOX in combination with the control groups, were used. Uniform discs were made from a Teflon mold containing control and experimental materials which were mixed as per manufacturer's instructions. Antibiotics were combined in a proportion of 1.5% w/w, as given in [Table 1] and [Table 2].
Table 1: Proportion of the experimental materials added to Conventional GIC Group

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Table 2: Proportion of the experimental materials added to Bulk-Fill Alkasite Cement group

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Test organisms

Two microorganisms selected for the study were wild strains of Lactobacillus spp. and S. mutans. The purity was assessed at 35°C for 48 h prior to testing of the extracts.

Inoculum preparation

In the study, the log-phase method was executed. At least three to five well-isolated colonies of the same morphological type were selected from agar culture plate further, each colony was scooped with a loop, and the growth was transferred into a tube containing 4–5 mL BHI broth. The broth culture was incubated at 35°C for 2–6 h until it achieved a turbidity of 0.5 McFarland standards. The turbidity of actively growing broth culture was adjusted with broth to obtain a final turbidity optically comparable to that of the 0.5 McFarland standards, done visually by comparing the inoculum tube and the standards against a white card with contrasting black lines.

Antibacterial efficacy using agar well diffusion assay

The agar well diffusion assay method was followed for determining the zones of inhibition of test material. The Mueller-Hinton agar was used to prepare the Petri plates upon autoclaving and kept for setting or solidifying for 10–15 min. The targeted test organism of 0.1 mL was added to media plates and spread with sterile cotton swabs evenly throughout the plates. After 10 min, agar wells were made with appropriate diameter borers. The test material discs were added to wells, and the plates were kept in an incubator at 37°C for growth. The zones of inhibition were recorded with zone interpretation scale [Figure 1] and [Figure 2].
Figure 1: Represent inhibition zones (in triplicate experiment) achieved by conventional glass-ionomer cement, conventional glass-ionomer cement + doxycycline, and conventional glass-ionomer cement + double antibiotic paste against Lactobacillus spp. and Streptococcus mutans, respectively

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Figure 2: Represent inhibition zones (in triplicate experiment) achieved by bulk-fill alkasite cement, bulk-fill alkasite cement + doxycycline, and bulk-fill alkasite cement + double antibiotic paste against Lactobacillus spp. and Streptococcus mutans, respectively

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   Results Top


Data from the agar diffusion tests using CGIC and bulk-fill alkasite cement combined with DOX and DAP against S. mutans and Lactobacillus spp. are given in [Table 3] and [Table 4].
Table 3: Inhibition zones in millimetre for conventional Glass Ionomer Cement Group

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Table 4: Inhibition zones in millimetre for Bulk-Fill Alkasite Cement (Cention N) Group

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Intragroup comparison

The triplicate experiment using CGIC with and without antibiotic against S. mutans and Lactobacillus spp. is shown in [Figure 1]. The mean antibacterial efficacy of CGIC against S. mutans was seen to be zero, whereas against Lactobacillus spp., the control group gave a mean of 3.67 with a standard deviation (SD) of 6.35 [Figure 3].
Figure 3: Mean antibacterial efficacy of conventional glass-ionomer cement with and without antibiotics

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Irrespective of the organism tested, the mean antibacterial efficacy of CGIC without addition of antibiotics was found to be 1.83. When combined with DAP, antibacterial efficacy was found to be 22.83 with SD of 6.01. The mean antibacterial efficacy of CGIC with DOX was 27.33 with SD of 10.13 [Figure 2]. The comparison between antibacterial efficacy of CGIC and CGIC with DAP and DOX was seen to be statistically highly significant with P = 0.0006 and P = 0.0001, respectively (P < 0.05).

The mean antibacterial efficacy of the bulk-fill alkasite cement (Cention N) against S. mutans and Lactobacillus spp. was 13.0.A mean antibacterial efficacy of 27.17 was seen against the organisms when Double Antibiotic Paste(DAP) was added to Cention N. Addition of DOX to Cention N gave a mean antibacterial efficacy of 28.50 [Figure 4]. Intragroup comparison of the control and experimental groups gave a significant P value. Comparison of the control group with DAP and DOX group yielded P = 0.0147 and P = 0.0080, respectively (P < 0.05).
Figure 4: Mean antibacterial efficacy of Cention N with and without antibiotics

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Intergroup comparison

Comparison was also done between CGIC combined with antibiotics against the bulk-fill alkasite cement (Cention N) combined with antibiotic. While comparison of the two control groups without antibiotics yielded a mean antibacterial efficacy of 1.83 for CGIC and 13.00 for the bulk-fill alkasite cement (Cention N), it was seen that irrespective of the organisms tested, the antibacterial efficacy increased significantly when antibiotics were added to CGIC.


   Discussion Top


Our study shows the effect of adding antibiotics to CGIC and a bulk-fill alkasite cement (Cention N). In addition to this, in our study, the antibacterial efficacy of the materials without addition of antibiotics is also shown. The results of our study show promising antibacterial properties of the tested experimental materials.

GIC has been known to be antibacterial, possibly due to the release of fluoride, though this has not been reliable. Many authors report no antibacterial efficacy of fully set CGIC.[9],[10] Our study supports this, as no inhibition zone was found in CGIC (control group) which is a significant finding (mean antibacterial efficacy = 1.83), although this may be due to limited activity of fluoride after setting reaction is completed.[10]

The difference in the CGIC (control group) and the two experimental groups is statistically highly significant with P = 0.0006 for DAP containing ciprofloxacin and metronidazole and P = 0.0001 for DOX, respectively (P < 0.05). This finding signifies that addition of antibiotics to CGIC will benefit the overall antibacterial efficacy of the material. This finding coincides with other similar studies.[11],[12],[13]

Cention N is a newer bulk-fill alkasite cement. There is scanty evidence as to its antibacterial efficacy. Our study findings conclude that the bulk-fill alkasite cement (Cention N) has higher antibacterial efficacy (mean antibacterial efficacy = 13) as compared to CGIC (mean antibacterial efficacy = 1.83). Addition of antibiotics to this material also significantly increased its antibacterial efficacy. The difference in antibacterial efficacy of the control group and experimental groups is statistically significant with P = 0.0147 for the DAP group and P = 0.0080 for the DOX group (P < 0.05), although it is our view that further studies regarding physical properties of the cement on addition of experimental materials are required.

Antibiotics have been used in dentistry in oral formulations as well as in paste form in local treatment of infections. They have also been used widely in the field of periodontics. The rationale of using two different antibiotic pastes is that a greater efficacy may be achieved due to mixed microflora. To avoid the development of resistance, mixture of antibiotics like DAP containing ciprofloxacin and metronidazole is better than a single antibiotic.

It has been known from previous studies that addition of antibiotics or other materials to GIC diminishes its physical properties. A study by Prabhakar et al. showed that 1% antibiotic mixture (ciprofloxacin and metronidazole) enhanced the antibacterial efficacy of CGIC without affecting shear strength.[13] Yesilyurt et al. also found that addition of antibiotics in 1.5% w/w (ciprofloxacin, metronidazole, and minocycline) increased antibacterial efficacy and least affected physical properties.[10] Hence, our study included addition of 1.5% w/w of antibiotics to CGIC and bulk-fill alkasite cement (Cention N).

The main mechanism of action of the novel material seems to be due to the effect of the added antibiotics on the structure of the microorganisms. DOX inhibits protein synthesis by binding to 30S ribosomal subunit. Metronidazole acts by inhibiting the nucleic acid synthesis by disrupting the DNA of microbial cells, whereas ciprofloxacin inhibits DNA replication by inhibiting bacterial DNA topoisomerase and DNA gyrase.

Comparative analysis of two antibiotics (DOX and DAP) did not give a statistically significant difference between the antibacterial efficacies. Nevertheless, DOX shows slightly higher antibacterial efficacy as compared with the double antibiotic group. In spite of this finding, DOX gives a yellow hue to the cement which may present as a drawback to the esthetics, but this needs to be further tested.

In our experiment, wild strains of S. mutans and Lactobacillus spp. have been used since these organisms are commonly isolated from carious lesions. It was also seen that with respect to organisms, Lactobacillus spp. gave higher zones of inhibition as compared to S. mutans. This was probably due to higher susceptibility of Lactobacillus spp. to the antibiotics.

In practice, this novel material has a variety of applications ranging from incomplete carious removal in primary teeth to liners in permanent teeth. It shows promising usefulness in atraumatic dentistry treatment. Further in vivo studies utilizing this material are required for better clinical application. Thus, addition of antibiotics such as DOX and DAP containing ciprofloxacin and metronidazole to CGIC and bulk-fill alkasite cement (Cention N) increases its antibacterial efficacy.


   Conclusion Top


Through the results of this in vitro study, we concluded the following:

  1. Fully set CGIC has minimal antibacterial efficacy against S. mutans and Lactobacillus spp.
  2. Addition of antibiotics such as DOX and DAP containing metronidazole and ciprofloxacin to CGIC and bulk-fill alkasite cement (Cention N) significantly increases the antibacterial efficacy of these restorative materials.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Yee R, Sheiham A. The burden of restorative dental treatment for children in third world countries. Int Dent J 2002;52:1-9.  Back to cited text no. 1
    
2.
Martins-Júnior PA, Vieira-Andrade RG, Corrêa-Faria P, Oliveira-Ferreira F, Marques LS, Ramos-Jorge ML, et al. Impact of early childhood caries on the oral health-related quality of life of preschool children and their parents. Caries Res 2013;47:211-8.  Back to cited text no. 2
    
3.
Wilson AD, Kent BE. The glass-ionomer cement, a new translucent dental filling material. J Appl Chem Biotechnol 1971;21:313.  Back to cited text no. 3
    
4.
Sakaguchi RL, Powers JM. Craig's Restorative Dental Materials. 13th ed: Elsevier; 2012.p 34-36.  Back to cited text no. 4
    
5.
Sidhu SK. Clinical evaluations of resin-modified glass-ionomer restorations. Dent Mater 2010;26:7-12.  Back to cited text no. 5
    
6.
Nicholson JW, Swift EJ. Ask the experts: Is there a place in dentistry for compomers. J Esthet Restor Dent 2008;20:3-4.  Back to cited text no. 6
    
7.
Todd JC. Scientific Documentation: Cention N. Schaan, Liechtenstein: Ivoclar-Vivadent Press; 2016. p. 1-58.  Back to cited text no. 7
    
8.
Adl A, Hamedi S, Sedigh Shams M, Motamedifar M, Sobhnamayan F. The ability of triple antibiotic paste and calcium hydroxide in disinfection of dentinal tubules. Iran Endod J 2014;9:123-6.  Back to cited text no. 8
    
9.
Yap AU, Khor E, Foo SH. Fluoride release and antibacterial properties of new-generation tooth-colored restoratives. Oper Dent 1999;24:297-305.  Back to cited text no. 9
    
10.
Yesilyurt C, Er K, Tasdemir T, Buruk K, Celik D. Antibacterial activity and physical properties of glass-ionomer cements containing antibiotics. Oper Dent 2009;34:18-23.  Back to cited text no. 10
    
11.
Ferreira JM, Pinheiro SL, Sampaio FC, Menezes VA. Use of glass ionomer cement containing antibiotics to seal off infected dentin: A randomized clinical trial. Braz Dent J 2013;24:68-73.  Back to cited text no. 11
    
12.
Mittal S, Soni H, Sharma DK, Mittal K, Pathania V, Sharma S, et al. Comparative evaluation of the antibacterial and physical properties of conventional glass ionomer cement containing chlorhexidine and antibiotics. J Int Soc Prev Community Dent 2015;5:268-75.  Back to cited text no. 12
    
13.
Prabhakar AR, Prahlad D, Kumar SR. Antibacterial activity, fluoride release, and physical properties of an antibiotic-modified glass ionomer cement. Pediatr Dent 2013;35:411-5.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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