Redefining the persistent infection in root canals: Possible role of biofilm communities

Current concepts suggest that persisting infections subsequent to endodontic therapy are caused by one or two bacterial species that are too robust to be eliminated by conventional treatment measures. As a consequence, numerous studies are exploring the characteristics of these most resistant organisms to define an effective treatment strategy to eradicate them from root canals. By taking an ecological perspective, the main objective of this review is to present evidence that the nature of persisting endodontic infections depends not on the robustness of the organisms in the infected site, but on their capability of adapting their physiology to the new environmental conditions set by the treatment. Changes in the environment, such as an increase in pH by calcium hydroxide or the effect of antimicrobials, are capable of triggering genetic cascades that modify the physiological characteristics of bacterial cells. Surface adherence by bacteria to form biofilms is a good example of bacterial adaptation and one that is pertinent to endodontic infections. Increasing information is now available on the existence of polymicrobial biofilm communities on root canal walls, coupled with new data showing that the adaptive mechanisms of bacteria in these biofilms are significantly augmented for increased survival. This ecological view on the persisting infection problem in endodontics suggests that the action of individual species in persisting endodontic infections is secondary when compared to the adaptive changes of a polymicrobial biofilm community undergoing physiological and genetic changes in response to changes in the root canal environment.