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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Antimicrobial Efficacy of Calcium Hydroxide with Different Herbal Additives: An In-vitro Study
Correspondence Address :
Pragna S Vijaya,
Postgraduate Student, Department of Pediatric and Preventive Dentistry, Rajarajeswari Dental College and Hospital, Ramohalli Cross, Mysore Road, Bengaluru, Karnataka, India.
E-mail: pragnasv98@gmail.com
Introduction: Microorganisms such as Enterococcus faecalis, Enterobacteriaceae, and Candida albicans are associated with persisting infections and can cause endodontic failure. The addition of herbal additives such as Triphala, Clove, and Activated charcoal to Calcium hydroxide enhances the microbial efficacy within the root canal.
Aim: To evaluate and compare the anti-microbial efficacy of calcium hydroxide with various herbal additives against E. faecalis and C. albicans using Agar Diffusion Test (ADT) and Direct Contact Test (DCT).
Materials and Methods: The present in-vitro study was conducted in Bangalore, Karnataka, between July 2023 and September 2023. Ethical clearance was obtained from the institution. Sabouraud Dextrose Agar (SDA) and Mueller-Hinton Agar were prepared and used to culture C. albicans and E. faecalis, respectively. In each plate, four wells were filled with groups (n=10): Group-I: Nanocalcium hydroxide (NCH)+sterile distilled water, Group-II: NCH+Nanoparticle Clove, Group-III: NCH+Nanoparticle Triphala, Group-IV: NCH+nanoparticle activated charcoal. The plates were incubated at 37°C, and zones of inhibition around the wells were measured on the first, third, and seventh day. DCT was evaluated in Colony Forming Units (CFUs)/ml by adding each bacterial suspension to four groups and inoculating on blood agar plates. One-way ANOVA test followed by Tukey’s post-hoc analysis was used to compare the mean Zone Of Inhibition (ZOI). Kruskal-Wallis Test followed by Mann-Whitney post-hoc test was used to compare the mean CFUs.
Results: One-way ANOVA test showed that there was a significant difference in the mean ZOI between the four groups at p=0.005. The maximum mean ZOI against C. albicans was achieved by the combination of calcium hydroxide and clove with an average mean of 22.20±1.92 mm, 20±1.87 mm, and 17.20±2.28 mm on the 1st, 3rd, and 7th day, respectively. Calcium hydroxide with distilled water combination showed the highest mean ZOI against E. faecalis with an average mean of 18.20±0.84 mm on day 1, 17±1 mm on the 3rd and 7th day. The mean CFUs of E. faecalis and C. albicans showed a significant difference between the four groups at p<0.001.
Conclusion: The addition of herbals to Calcium hydroxide increased anti-microbial activity against Candida albicans and Enterococcus faecalis.
Activated charcoal, Candida albicans, Enterococcus faecalis, Triphala
Microorganisms play a vital role in the aetiology of pulp and periapical diseases (1). An important and fundamental goal of root canal treatment is to eliminate bacteria from the root canal to prevent re-infection (2). Although endodontic infections are reduced by the chemo-mechanical preparation of the root canal, microorganisms can still persist in the complex root canal system (3).
Certain microbial species such as Enterococcus faecalis (E. faecalis), Enterobacteriaceae, and Candida albicans (C. albicans) are associated with persisting infections and can cause endodontic failure. Researchers have found C. albicans in 18% of cases, always associated with other bacteria, and E. faecalis in 50% of cases (4). Their persistence can be explained by their tolerance to anti-microbials and ability to survive in a nutrient-deficient environment (5). The proportional decrease of facultative bacteria and the concomitant increase of strictly anaerobic bacteria with time are because of oxygen consumption and low oxidation-reduction potential, which collaborate to sustain the growth of these bacteria (6). Intracanal medicaments are considered mandatory in the management of such cases. Calcium hydroxide is the gold standard material and is widely used as an intracanal medicament for disinfection and to promote periapical healing. The anti-microbial activity is attributed directly to the dissociation and availability of calcium and hydroxyl ions resulting in increased local pH. These hydroxyl ions have the ability to destroy the cytoplasmic membrane, denature bacterial proteins, and damage bacterial DNA (7).
Gum and dental issues have traditionally been treated using herbal treatments. In the recent era, herbal extracts have been used in dentistry as anti-microbials, antiseptics, and anti-bacterials. Clove (Syzygium aromaticum), belonging to the family Myrtaceae, is an important culinary plant with immense medicinal use. Clove has been shown to have anti-microbial effects against a variety of bacterial and fungal species. An in-vitro study showed that at a 5% concentration of clove extract, there was no anti-microbial activity, while 10% and 50% concentrations showed anti-microbial activity against E. faecalis. Anti-microbial activity increased as the concentration increased from 5 to 50% (8).
Triphala is an Indian Ayurvedic herbal formulation consisting of dried and powdered fruits. It is an equi-proportional mixture of Terminalia chebula, Terminalia belerica, and Emblica officinalis in a 1:1:1 ratio and is used as a potent anti-inflammatory, antioxidant, and anti-microbial agent against a wide spectrum of microbes (9). An in-vitro study demonstrated that Triphala extract had anti-microbial properties against C. albicans with a maximum ZOI of 20 mm at 9% (10). Activated charcoal is a black, odourless, flavourless powder with anti-bacterial efficacy that has been used as an emergency anti-poison treatment since the 1800s, as it can bind to a wide variety of drugs, reducing their effects (11).
Nanoparticles are microscopic particles of less than 100 nm in size. The nano form of calcium hydroxide penetrates dentinal tubules and enhances anti-microbial efficacy due to its extended presence in dentinal tubules (12). An alternative treatment approach has been developed to treat infections using traditional medicinal herbs, which is clinically safer in combating the negative effects of drug resistance and side effects associated with commonly used antibiotics. Considering the lack of research on the anti-bacterial properties of calcium hydroxide with herbal additives and the advantages of using naturally available herbs, the current in-vitro study was undertaken to evaluate and compare the effect of adding various herbal extracts on the anti-bacterial efficiency of different calcium hydroxide formulations.
This in-vitro study was conducted at the Department of Microbiology, Rajarajeswari Medical College and Hospital in Bangalore, India from July 2023 to September 2023. The study received approval from the ethical committee of the institution (RRDCH/IEC/2023/88).
Sample size estimation: The sample size was estimated using GPower software v. 3.1.9.4 (Franz Faul, Universität Kiel, Germany). The sample size estimation was performed at a 5% alpha error level (α=0.05), with an effect size of 0.58 (based on the findings from the previous literature by Somayaji SK et al.,) (13), and the study’s power set at 80%, indicating that a minimum of 40 samples was needed for the present study. Each group consisted of 10 samples (10 samples×4 groups=40 samples). The sample size in each study group was further subdivided into five samples for ADT and DCT for E.faecalis and C.albicans (5 samples×2 tests×4 groups×2 organisms=80 samples).
Procedure
The pure strains of E.faecalis and C.albicans were obtained from the Microbial Type Culture Collection (MTCC) at Rajarajeswari Medical College and Hospital, Bengaluru, Karnataka, India. SDA and MHA media were used to assess the effect of different intracanal medicaments on the growth of C.albicans and E.faecalis, respectively, using the ADT. Blood agar medium was used to evaluate the impact of various intracanal medicaments on the growth of C.albicans and E.faecalis using the DCT.
Preparation of Sabouraud Dextrose Agar (SDA) and Mueller-Hinton Agar (MHA): Six grams of SDA and MHA were added to 150 ml of distilled water and then heated to dissolve the agar. Autoclaving was then performed for 15 minutes at 121°C to ensure adequate sterilisation. The mixture was then poured into Petridishes and left to cool and solidify.
Preparation of E. faecalis and C. albicans Suspension: A sterile swab was used to transfer C. albicans and E. faecalis growth from the primary culture into the SDA and MHA broth bottles, respectively, and mixed well to form a homogeneous suspension.
Preparation of intracanal medicaments: Two grams of NCH powder (Nanoresearch Laboratory, Jharkhand) were dissolved in 5 mL of distilled water to obtain a liquid consistency, resulting in a 40% concentration solution in a test tube (14). Additionally, 0.1 gram of nanoparticle Triphala powder (Nanoresearch Laboratory, Jharkhand), 0.5 gram of nanoparticle clove powder (Nanoresearch Laboratory, Jharkhand), and 0.5 gram of nanoparticle activated charcoal powder (Nanoresearch Laboratory, Jharkhand) were added to three different test tubes and dissolved with 1 mL of sterile distilled water. Then, 1 mL of the prepared NCH mixture was added to each test tube to obtain three different formulations (15).
Anti-microbial assay: The anti-microbial activity of different formulations of nanoparticle calcium hydroxide was determined using the agar well diffusion method (Table/Fig 1). The plates were left at room temperature for one hour and then incubated at 37°C for seven days. Zones of inhibition (in millimeters) were measured at one, three, and seven days.
Direct Contact Test (DCT): Tryptic Soy Broth (TSB) was used to cultivate E. faecalis and C. albicans, and the cultures were kept for 48 hours at 37°C. The microbial cells were re-suspended in saline to obtain a bacterial solution with 1.5×108 cells/mL and a concentration of 0.5 McFarland. Subsequently, the tubes with different formulations were inoculated with 0.01 mL of each bacterial suspension, and then incubated for 24 hours at 37°C (14). Blood agar plates were used as the medium and divided into groups (Group-I, II, III, and IV). A sterilised inoculating loop was used to inoculate the samples on the blood agar plate using the streak plate method. The anti-microbial activity was evaluated by counting Colony Forming Units (CFUs) after 24 hours.
Statistical Analysis
The Statistical Package for Social Sciences (SPSS) for Windows version 22.0, released in 2013 by IBM Corp. in Armonk, NY, was used to perform statistical analyses. A one-way Analysis of Variance (ANOVA) test followed by Tukey’s post-hoc analysis was used to compare the mean ZOI (in mm) against E. faecalis and C. albicans between groups at different time intervals. Repeated measures of ANOVA test followed by Bonferroni’s post-hoc test were used to compare the mean ZOI against E. faecalis and C. albicans. The Kruskal-Wallis test followed by the Mann-Whitney post-hoc test was used to compare the mean CFUs of E. faecalis and C. albicans between groups. The level of significance (p-value) was set at p<0.05.
(Table/Fig 2),(Table/Fig 3) show the mean ZOI against C. albicans between different time intervals in each group. The maximum mean ZOI of 22.20±1.92 mm was achieved by Group-II. On day 3, there was a statistically significant difference in the mean ZOI between groups at p=0.005. On day 1 and day 7, there was no statistically significant difference between groups. (Table/Fig 4) shows the multiple comparison of mean differences between groups, revealing that Group-4 showed a significantly lesser mean ZOI compared to Group-2 and Group-3, which was statistically significant at p=0.004 and p=0.02, respectively. However, no significant difference was observed between the other groups.
(Table/Fig 5),(Table/Fig 6) show the mean ZOI against E. faecalis between different time intervals in each group. The maximum mean ZOI of 18.20±0.84 mm was achieved by Group-1. On Day 1, there was no statistically significant difference between the groups, while on Day 3 and Day 7, there was a statistically significant difference in the mean ZOI between the groups at p=0.04 and p<0.001, respectively. (Table/Fig 7) shows the multiple comparison of mean differences between groups on Day 3, revealing that Group-4 showed a significantly lesser mean ZOI compared to Group-1, which was statistically significant at p=0.04. Multiple comparisons on Day 7 revealed that Group-1 showed a significantly higher mean ZOI compared to Group-2, 3, and 4, which was statistically significant at p=0.04, p=0.02, and p<0.001, respectively. However, no significant difference was observed between the other groups.
For mean Colony-Forming Units (CFUs) of C. albicans and E. faecalis, there was a significant difference between the groups at p<0.001 as shown in (Table/Fig 8). Multiple comparisons of mean differences between groups revealed that the mean CFUs of C. albicans and E. faecalis were significantly higher in Group-3 compared to the other groups (Table/Fig 9),(Table/Fig 10),(Table/Fig 11).
The present study investigated the efficacy of the combination of nanoparticle calcium hydroxide with various herbal formulations as an intracanal medicament against Enterococcus faecalis and Candida albicans. The main purpose of endodontic treatment is the elimination of microbiota from the root canal system, a major challenge for all endodontic practitioners. While sporadic species of bacteria affecting the root canal system have a low virulence impact individually, collectively they have a significant virulence impact (16).
Microbial virulence factors include toxins, hydrolytic enzymes, cell surface proteins, and carbohydrates that mediate microbial attachment and protection from the host. Therefore, the goal of root canal treatment is to significantly reduce the number of bacteria and bacterial biofilms by eradicating and killing them, and to modify the conditions in the root canal system to be less favourable for microbial growth (2).
The most commonly used techniques to demonstrate the anti-bacterial activities of materials are the ADT and the DCT. ADT is an accepted method for initially differentiating anti-bacterial activity between materials, and the result depends on the anti-bacterial activity of the material for the particular microorganism and is highly influenced by the diffusibility of the material across the medium (16). DCT relies on direct and close contact between the test microorganism and the test material, which is virtually independent of the diffusion characteristics of the media and the tested material. These two methodologies were used in the current study (17).
Candida albicans is the most abundant fungus found in the oral cavity and often causes endodontic treatment failure. Enterococcus faecalis is one of the most persistent bacteria frequently detected in root canal therapy (4). The use of intracanal medications may significantly increase the success of root canal treatment by reducing or eliminating bacteria in the root canal system. The material of choice for intracanal medication is calcium hydroxide due to its beneficial properties, such as anti-microbial activity, capacity to limit inflammation, ability to dissolve organic tissues, and inactivation of bacterial endotoxins (2). Calcium hydroxide has been reported to require a minimum of seven days of contact time to completely eliminate any bacteria that might have survived the chemo-mechanical preparation (18). To be effective, calcium hydroxide should penetrate dentinal tubules to come in direct contact with microorganisms. Minimising the particle size and producing a nano form of calcium hydroxide may enhance the penetration of the material into the dentinal tubules and improve microbial efficacy due to the longer presence of the drug in the dentinal tubules. The higher surface-to-volume ratio and charge density of these nanoparticles result in their greater interaction with the environment and higher anti-bacterial activity (12). In the present study, the calcium hydroxide formulation achieved the maximum mean zone of inhibition against E. faecalis.
Modern developments in drug research technologies and the quest for unique chemical diversity have boosted efforts to investigate potential therapeutic leads from India’s traditional Ayurvedic system (4). The prevailing notion that “green medicine” is more reliable and safer than expensive synthetic medications, many of which have unfavourable side effects, is the primary reason for the current resurgence of interest in plant-derived pharmaceuticals. The constant increase in antibiotic-resistant strains of microorganisms and the deleterious effects caused by synthetic drugs have led researchers to search for herbal alternatives that are non-toxic or less toxic (9).
The essential oil of cloves is used as a painkiller for dental emergencies in Western herbalism, Chinese medicine, Indian Ayurvedic medicine, and Western medicine. Clove oil is abundantly available, easily accessible, economically feasible, and culturally acceptable, with minimal side effects. It is used in the preparation of toothpastes, laxative pills, and clovacaine solution, a local anaesthetic used in oral ulceration and inflammation (8). In the present study, the calcium hydroxide with clove formulation showed a maximum mean ZOI of 22.20±1.92 mm and 17.60±1.14 mm against C. albicans and E. faecalis, respectively. A similar study by Niharika P, showed the anti-bacterial effect of clove and tulsi against E. faecalis when compared to calcium hydroxide (19).
Triphala is an herbal mixture used extensively in the Indian system of medicine. The active constituents present in Triphala, such as tannic acid, chebulic acid, and flavonoids, are largely responsible for its therapeutic potential (9). In the present study, the calcium hydroxide with triphala formulation showed a mean ZOI of 21.60±0.89 mm and 17.40±0.89 mm on day 1 against C. albicans and E. faecalis, respectively.
Activated charcoal is a natural product used in oral and dental care preparations (11). In the present study, the calcium hydroxide with activated charcoal formulation showed a significantly smaller mean ZOI compared to the other groups. Similar studies from the literature have been discussed in (Table/Fig 12) (15),(16),(19),(20).
Limitation(s)
All these experiments were conducted under in-vitro conditions; further studies should be carried out to assess the effects of these nanoparticles in clinical settings, as in-vivo conditions vary significantly. The actions and effects of these intracanal medicaments may differ when interacting with periradicular tissues compared to in-vitro controlled conditions. Another limitation of the study could be the small sample size for each group, which could impact the reliability of the findings.
The placement of intracanal medicament plays a fundamental role in eliminating endotoxins produced by microbial pathogens. Within the limitations of the study, it can be concluded that the Nanoparticle clove formulation showed the highest mean ZOI against Candida albicans, while the Nanoparticle calcium hydroxide formulation showed the highest mean ZOI against Enterococcus faecalis when compared to the other three groups. The use of herbal alternatives as intracanal medicament could be safer and more effective, with an additive or synergistic positive effect, as the combination of medications may reduce the development of resistant bacterial strains and ultimately encourage a synergistic action with increased anti-bacterial efficacy.
DOI: 10.7860/JCDR/2024/70295.19764
Date of Submission: Feb 22, 2024
Date of Peer Review: Apr 09, 2024
Date of Acceptance: Jul 06, 2024
Date of Publishing: Aug 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA
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