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Enhanced Antimicrobial and Immunomodulatory Effects of Calcium Hydroxide Combined with NSAIDs Against Enterococcus
Hanan Abdullatef1, Omar Omar2,3, Jaffar Aldandan1
1Department of Restorative Dental Sciences, Imam Abdulrahman Bin Faisal University College of Dentistry, Dammam, Saudi Arabia.
Objective:
This study aims to evaluate i) the antimicrobial and immunomodulatory effects of calcium hydroxide (Ca(OH)2) when combined with nonsteroidal anti-inflammatory drugs (NSAIDs) against Enterococcus faecalis (E. faecalis), and ii) to assess the inflammatory and cytocompatibility responses of this combination in human peripheral blood mononuclear cells (PBMCs).
Methods:
Three-week-old E. faecalis biofilms were developed on human dentine blocks and subsequently treated for 1 week with Ca(OH)2 alone or combined with 20% ketoprofen (Keto), 20% diclofenac sodium, or gentamicin. Biofilm disruption was assessed using scanning electron microscopy (SEM), while gelatinase (GelE) activity served as a marker of bacterial virulence. Culture supernatants were used to stimulate PBMCs in vitro for 24 hours. The immunomodulatory responses of PBMCs were evaluated using fluorescence microscopy, NucleoCounter NC-202™ cell analysis for live/total cell counts and viability, and ELISA for TNF-α and IL-1β secretion.
Results:
All medicated groups showed significantly reduced GelE activity compared to untreated controls, with the most substantial suppression observed in the Ca(OH)2 + diclofenac group. While Ca(OH)2 + diclofenac and Ca(OH)2 + gentamicin were most effective in reduceding TNF-α and IL-1β levels, Ca(OH)2 + diclofenac was also associated with the lowest PBMCs viability and highest cell aggregation. Ca(OH)2 + Keto preserved PBMCs viability while maintaining anti-inflammatory and antimicrobial effects.
Conclusion:
Combining Ca(OH)2 with diclofenac sodium or Keto enhances the antimicrobial and immunomodulatory efficacy of Ca(OH)2 against E. faecalis biofilms. Ca(OH)2 + diclofenac reduced PBMCs viability, suggesting a strong immunosuppressive effect that may be beneficial in dampening excessive inflammation but also raises concerns regarding cytocompatibility and dose optimization. Ca(OH)2 + keto demonstrated a more favourable balance between antimicrobial activity and biocompatibility, supporting its potential as a non-antibiotic adjunct in intracanal medication protocols.
