Review Article
Correlation between Enterococcus faecalis and
Persistent Intraradicular Infection Compared with Primary
Intraradicular Infection: A Systematic Review
Chenjiao Zhang, MS,* Jianrong Du, MS,† and Zhixiang Peng, PhD*
Abstract
Introduction: The relationship between Entero-
coccus faecalis and pulpal or periradicular diseases
has been studied for many years; however, whether E.
faecalis is correlated with persistent intraradicular
infections (teeth after failed endodontic treatments)
compared with primary intraradicular infections remains
controversial. The objective of this systematic review
was to compare the prevalence of E. faecalis in primary
and persistent intraradicular infections. Methods: An
exhaustive literature search combined with specified in-
clusion criteria was performed to collect all studies
comparing the prevalence of E. faecalis in root canals
with primary and persistent intraradicular infections.
Descriptive statistics were applied first because of the
high heterogeneity among studies. Subgroup analysis
according to different detecting methods (culture and
polymerase chain reaction) and sensitivity analysis was
then applied. Meta-analysis was conducted with the
help of Stata/SE 12.0 (StataCorp, College Station, TX) af-
ter excluding studies with uncertain forms of pulpal and
periradicular lesions in their primary infection groups.
Results: The systematic review included 10 studies
covering 972 teeth. Among them, 2 studies used the cul-
ture technique, 6 studies used polymerase chain reac-
tion, and the other 2 used both techniques. The
detection rate of E. faecalis by both methods was
higher in persistent infections compared with untreated
chronic periapical periodontitis as primary infections. The
difference was statistically significant (odds ratio = 7.247;
95% confidence interval, 4.039–13.002). Conclusions:
E. faecalis is more highly correlated with persistent in-
traradicular infections compared with untreated chronic
periapical periodontitis. (J Endod 2015;-:1–7)
Key Words
Enterococcus faecalis, persistent intraradicular
infection, primary intraradicular infection, systematic
review
From the *Department of Operative Dentistry and Endodontics, Guanghua School and Hospital of Stomatology, Institute of Stomatological Research, Guangdong
Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, China; and †Department of Stomatology, Guangdong No. 2 Provincial Peo-
ple’s Hospital, Guangdong, China.
Address requests for reprints to Prof Zhixiang Peng, Department of Operative Dentistry and Endodontics, Guanghua Hospital of Stomatology, 56 Ling Yuan Xi Road,
Guangzhou 510055, China. E-mail address: 13430371987@163.com
0099-2399/$ - see front matter
Copyright ª 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.04.008
JOE — Volume -, Number -, - 2015
N ormally, the success rate of root canal therapy under aseptic conditions ranges
from 70%–95% (1). The presence of persistent infection is the main reason for
the failure of endodontic treatment (2). Microbial species found in the root canals after
failed endodontic therapy are limited compared with those found in untreated ones.
Gram-positive and facultative anaerobes are the most frequently isolated species within
treated canals and around the periapical area. Among them, Enterococcus faecalis is
the most prevalent (3–5).
E. faecalis is a species of the genus Enterococcus. It is a metabolism fermentative,
facultatively anaerobic, gram-positive coccus that does not form endospores (6). Re-
searchers began to investigate the association of E. faecalis with intracanal infections
since the 1960s using microbiological culturing techniques. Since then, E. faecalis has
been frequently found in persistent intraradicular infections after failed endodontic
treatments (3, 4, 7–9). In recent years, molecular methods such as polymerase
chain reaction (PCR) have been introduced to this field, and the diagnostic
sensitivity of detection has been greatly increased. Most of the PCR amplification
methods detecting enterococci target the bacterial 16S or 23S ribosomal RNA gene
(rDNA), the tuf gene, or the dll gene (10, 11). Whole genomic DNA probes and
checkerboard DNA-DNA hybridization assay are also applied in detecting bacteria (12).
Several studies have compared the frequency of E. faecalis detected in persistent
and primary intraradicular infections (13–22). Some of them showed that E. faecalis
is more often associated with failed endodontic treatments than primary infections
(13–17, 19–21), whereas others indicate that no statistical difference was found
between them (18, 22). This topic remains unresolved. The objective of this
systematic review was to compare the prevalence of E. faecalis in primary and
persistent intraradicular infections. The result may help us affirm the reasons for
persistent infections and thus guide clinical practice for increasing the success rate
of root canal therapy.
Materials and Methods
Literature Search
Studies comparing the correlation between E. faecalis and persistent/primary in-
traradicular infections conducted in humans were identified. Medline (1966–2014),
Embase (1966–2014) (via PubMed and embase.com), the Cochrane Controlled Trials
Register (CENTRAL), and China National Knowledge Internet (CNKI) (1982–2014)
were searched using the strategy ‘‘(((((((persistent[Title/Abstract]) OR refractory
[Title/Abstract]) OR primary[Title/Abstract] OR secondary[Title/Abstract]) OR post-
treatment[Title/Abstract])) AND ((lesion*[Title/Abstract]) OR infection*[Title/Ab-
stract]))) AND ‘‘Enterococcus Faecalis’’[Title/Abstract].’’ Languages of the publications
E. faecalis and Persistent Intraradicular Infection 1
Review Article
were restricted to English and Chinese during the search. A total of 188
studies were subjected to preliminary analysis. Two reviewers scanned
all titles and abstracts when available and decided whether or not they
were related to the topic. When information from the title and abstract
was not adequate in determining the article’s relevance, they were auto-
matically included in subsequent analysis. One hundred seventy-one ar-
ticles were excluded, and the 17 that remained were subjected to further
judgement.
Inclusion and Exclusion Criteria
The reviewers scrutinized full texts of the remaining articles; the
inclusion criteria were as follows:
1. Studies in which subjects were in good general health and without
contributory medical history
2. Primary infection groups included permanent teeth with necrotic
pulp or acute or chronic apical periodontitis
3. Persistent infection groups included permanent teeth with persistent
infections after failed endodontic treatments
4. Studies identified E. faecalis in both primary and persistent infec-
tions using the same methodology in the same study
5. Selected teeth had acceptable conditions for placing a rubber dam
The exclusion criterion was no comparison between the detection
rate of E. faecalis in primary and persistent infected teeth. References
of the identified articles were reviewed to make sure no relevant article
was missed. Disagreements between the reviewers were settled via
discussion.
Data Extraction and Quality Assessment
The odds ratio of the detection of E. faecalis in persistent and pri-
mary infections was set as the prespecified outcome for the meta-
analysis. The quality of the included studies was assessed using the
Newcastle-Ottawa scale (Table 1).
Statistical Analysis
The outcome measure was based on the binary variable, the num-
ber of teeth with detection of E. faecalis/without detection of E. faecalis.
For each study, odds ratios (ORs) along with 95% confidence intervals
(CIs) were calculated. The significance of discrepancies from different
studies was assessed using the Cochrane Q test and I2 statistics. A fixed-
effects model was chosen when moderate or smaller heterogeneity was
found among studies (P $ .1). When significant heterogeneity (P < .1)
was detected, a random-effects model was chosen to combine the data.
If heterogeneity still existed, descriptive analysis was applied.
Because of the different detection sensitivity of the culture and PCR
technique, we divided the outcomes into 2 subgroups. Subgroup anal-
ysis was performed to investigate the relevance of the 2 different detect-
ing methods and the outcomes.
Sensitivity analysis was used to explore the origin of the heteroge-
neity. Stata/SE 12.0 was used to calculate and generate the graphs.
Results
Characteristics of the Included Studies
The final systematic review included 10 studies (13–22). The
main characteristics of the studies are presented in Table 1. Two of
them (13, 15) detected the presence of E. faecalis using the culture
technique, 6 of them used PCR, and the other 2 used both
techniques (18, 19).
On the basis of the Newcastle-Ottawa scale, 3 (14, 19, 22) of 10
studies got 6 points in quality assessment, 4 studies (13, 15, 16, 18)
got 7 points, and the other 3 studies (17, 20, 21) got 8 points. The
2 Zhang et al.
risks of bias of all the studies included are considered low. Sampling
procedures performed in all studies were standardized.
The Begg test and the funnel plot (Fig. 1) showed the existence of
publication bias in our meta-analysis (P = .027, <0.05 in total). In the
culture group, 4 studies (13, 15, 18, 19) involving 338 teeth were
included. Considerable heterogeneity was found between studies
(P = .00, I2 = 85%). In the PCR group, 8 studies (14, 16–22)
involving 802 teeth were included. Heterogeneity was still
considerable (P = .00, I2 = 86%). Because of the significant
heterogeneity among studies, descriptive analysis was applied
(Table 1). The results of the studies are presented in Table 1 and the
forest plot (Fig. 2). Three of 4 studies found E. faecalis was more often
correlated with persistent intraradicular infection compared with pri-
mary intraradicular infection in the culture group, whereas 6 of 8
studies in the PCR group reached the same conclusion.
Sensitivity Analyses
We excluded each study separately from the meta-analysis and
found out the study conducted by Sedgley et al in 2006 (19) is the origin
of heterogeneity for the culture group. Another 2 studies (18, 22) were
the heterogeneity source for the PCR group. In their studies, Dumani
et al and Gomes et al defined untreated teeth with necrotic pulps as pri-
mary infection, whereas Sedgley et al included teeth with the presence of
fistulae, persistent radiographic periapical lesions, or the presence of
symptoms in the primary infection group. Then, we inferred that the
different forms of pulpal and periradicular lesions in the primary infec-
tions might be the origin of the heterogeneity. Among all the studies, 4
(15–17, 20) of them only included chronic periapical periodontitis in
their primary infection groups. In addition, it was possible to extract
data regarding outcomes of teeth with chronic periapical
periodontitis as primary infection from another study (14).
We decided to exclude the studies with an uncertain form of pri-
mary infections and conduct a meta-analysis (Table 2, Fig. 3)
comparing the detection rate of E. faecalis in persistent intraradicular
infections and untreated chronic periapical periodontitis. In this way,
only 1 study (15) is qualified in the culture group, which indicates
that E. faecalis is more frequently found in persistent infections than
in primary infections and the difference was statistically significant
(OR = 108.308; 95% CI, 13.473–870.682). In the PCR group, 4 studies
(14, 16, 17, 20) were qualified and considered homogeneous
(P = .716, I2 = 0.0%). A publication bias test was not performed
because it is unrealistic to perform such a test accurately on a very
small number of studies. A fixed-effects model was then applied. The
detection of E. faecalis was more significantly associated with persistent
infections compared with primary infections (OR = 7.247; 95% CI,
4.039–13.002). When combining the 2 subgroups, the total heteroge-
neity among 5 studies was moderate (P = .099, I2 = 48.7%); the result
remained the same (OR = 10.646; 95% CI, 6.243–18.156).
Discussion
E. faecalis has been detected by various ratios in primary and
persistent intraradicular infections. According to the studies included,
the detection rate using the culture technique in primary and persistent
infections varies from 2%–13% and 8%–71% (13, 15, 18, 19),
whereas the rate using the PCR method varies from 5%–82% and
10%–76% (14, 16–22). This wide diversity may be attributed to the
sample size, the quality of initial treatment, the filling material, and
the different identification techniques.
Traditionally, bacteria in endodontic infections are studied using
the culture technique, which relies on the isolation, growth, and labo-
ratory identification according to morphology and biochemical tests.
However, the past decade has brought many advances in microbial
JOE — Volume -, Number -, - 2015
JOE — Volume -, Number -, - 2015

TABLE 1. Characteristics and Descriptive Analysis of the Included Studies

Periapical and No. of teeth No. of teeth
Periapical and pulpal lesion (detection of (detection of Detection Detection
pulpal lesion forms of E. faecalis/total) E. faecalis/total) rate (%), rate (%),
Detecting NOS forms of primary persistent in primary in persistent primary persistent 95% CI
Study Participants method score infections infections infections infections infection infection OR of OR
Gomes, 100 teeth Culture 7 Teeth had necrotic Teeth previously had 2/50 21/50 4 42 17.38 (3.79–79.61)
2006 (18) pulps with no prior root canal
endodontic treatments but
treatment showed
radiographic
evidence of apical
periodontitis
Guo, 90 teeth Culture 7 Teeth with chronic Root-filled teeth with 1/45 32/45 2 71 108.31 (13.47–870.68)
2011 (15) apical periodontitis persistent chronic
apical periodontitis
Gomes, 60 root canals Culture 7 Necrotic pulps Root-filled teeth with 2/41 6/19 5 32 9.00 (1.61–50.21)
2004 (13) radiographic
evidence of apical
periodontitis
Sedgley, 88 teeth Culture 6 Teeth with present of Endodontic failed 5/40 4/48 13 8 0.64 (0.16–2.55)
2006 (19) fistulae, persistent teeth undergoing
radiographic retreatments
periapical lesion, or
the presence of
symptoms
Foschi, 62 teeth ddl gene 8 Acute apical Endodontic infections 2/44 13/18 5 72 54.60 (9.45–315.41)
2005 (21) PCR periodontitis (teeth in failing cases
with clinical
symptoms but no
periapical
radiolucency),
chronic apical
periodontitis (teeth
with radiolucency
but no clinical
symptoms), and
E. faecalis and Persistent Intraradicular Infection

exacerbated apical
periodontitis (teeth
with symptoms and
radiolucency)
included
Gomes, 100 teeth 16S rDNA 7 Teeth had necrotic Teeth previously had 41/50 38/50 82 76 0.70 (0.26–1.83)
2006 (18) PCR pulps with no prior root canal
endodontic treatments but

Review Article
treatment showed
radiographic
evidence of apical
periodontitis
Gong, 60 teeth l6S rRNA 7 Teeth with chronic Root-filled teeth with 3/30 16/30 10 53 10.29 (2.56–41.37)
2012 (16) PCR apical periodontitis persistent chronic
apical periodontitis
(Continued )
3
 4

Review Article
TABLE 1. (Continued )
Periapical and No. of teeth No. of teeth
Zhang et al.

Periapical and pulpal lesion (detection of (detection of Detection Detection

pulpal lesion forms of E. faecalis/total) E. faecalis/total) rate (%), rate (%),
Detecting NOS forms of primary persistent in primary in persistent primary persistent 95% CI
Study Participants method score infections infections infections infections infection infection OR of OR
Dumani, 231 teeth l6S rRNA 6 Untreated teeth with Teeth with clinical 19/117 11/114 16 10 0.55 (0.25–1.22)
2012 (22) PCR necrotic pulps symptoms or
radiographic lesions
after failed
endodontic
treatments
Ozbek, 79 teeth 16S rRNA 8 Untreated teeth with Root-filled teeth with 9/36 32/43 25 74 8.73 (3.15–24.18)
2009 (20) PCR chronic apical clinical symptoms or
periodontitis radiographic lesions
Sedgley, 88 teeth 16S rRNA 6 Teeth with presence of Endodontic failed 27/40 43/48 68 90 4.14 (1.33–12.92)
2006 (19) PCR fistulae, persistent teeth undergoing
radiographic retreatments
periapical lesions, or
presence of
symptoms
Pirani, 102 teeth ddl gene 8 Untreated teeth with Root-filled teeth with 6/79 9/23 8 39 7.82 (2.40–25.47)
2008 (17) PCR periapical lesions periapical lesions
Rocas, 80 samples 16S rDNA 6 Acute apical Root-filled teeth 9/50 20/30 18 67 9.11 (3.20–25.96)
2004 (14) PCR periodontitis, associated with
chronic apical asymptomatic
periodontitis, and chronic
acute periradicular periradicular lesions
abscesses included
CI, confidence interval; NOS, Newcastle-Ottawa scale; OR, odds ratio; PCR, polymerase chain reaction; rDNA, ribosomal DNA.
JOE — Volume -, Number -, - 2015

Figure 1. Publication bias among studies is shown in the funnel plot. The x-
axis represents the logarithm of ORs of the studies, whereas the y-axis repre-
sents the standard error (se) of the logarithm of ORs. The nonsymmetric plot
indicated the existence of publication bias.
molecular diagnostics so the use of PCR can rapidly and accurately iden-
tify Enterococcus species with higher sensitivity (23). Except for regu-
lar PCR, real-time PCR (quantitative PCR) was also applied to detect the
prevalence of E. faecalis in the included studies (19, 20), which detects
specific gene targets in bacteria and allows quantification of bacteria in
samples.
The total sample size of the meta-analysis is 331. The conclusion
that E. faecalis is more prevalent in persistent infections than in primary
chronic periapical periodontitis reminds us that incautious root canal
treatment might be the cause of persistent infections of E. faecalis. The
organism may enter the root canal system at some time after the root
canal treatment has been initiated (24).
Figure 2. Detection results of primary and persistent infections. Each horizontal line represents a study, with the length of it depicting the 95% CI. The vertical line
represents no effect.
JOE — Volume -, Number -, - 2015
Review Article
The detection rate of E. faecalis in saliva ranges from 18.8%–
40.5% (25, 26). Some researchers think that the prevalence of E.
faecalis in root canals referred for endodontic retreatment is
associated with the presence of E. faecalis in saliva (27). It is the
most common enterococcal species found in the oral cavity occasion-
ally (24), and patients with periodontitis appear to harbor more E. fae-
calis than their counterparts with a healthy periodontium (26, 28, 29).
Therefore, the oral cavity might be the origin of E. faecalis entering root
canal systems, and the use of a rubber dam to insure good isolation is
necessary to prevent the introduction of E. faecalis during endodontic
treatment (30). Proper periodontal treatment or tooth cleaning before
root canal therapy in order to control periodontal inflammation may
reduce the amount of E. faecalis. E. faecalis is ubiquitous in many
food products, such as cheese and milk derivatives (31). Niches
such as root canal lumens and dentinal tubules may favor their survival
and long-standing local infection. In this way, for patients with good oral
hygiene, bacteria inside the root canal could be the consequence of a
coronal colonization after contaminated food ingestion (17) so a
good coronal sealing is also important in the prevention of E. faecalis.
Vidana et al (32) also think E. faecalis found in persistent endodontic
infections are probably not derived from the patient’s own normal mi-
crobiota, which indicates an exogenous origin. Consequently, the use of
the aseptic technique including the disinfection of obturation materials
might be critical in preventing the introduction of E. faecalis (33). It is
reported that 19.4% of gutta-percha cones removed from their
packaging contained bacteria on the surface (34); 5.25% sodium hypo-
chlorite and 2% chlorhexidine are the most common disinfectants for
gutta-percha cones. Povidone-iodine and peracetic acid have also been
studied for rapid disinfection (34–37).
Another popular opinion is E. faecalis involved in the persistent
infections may be those originally presented in the necrotic pulps that
have survived during the chemomechanical procedures and intracanal
medicaments (38, 39). E. faecalis is resistant to the antimicrobial effect
E. faecalis and Persistent Intraradicular Infection 5
Review Article
TABLE 2. Descriptive Analysis of the Studies with Chronic Perioapical Periodontitis as Primary Infections
No. of teeth No. of teeth
(detection of (detection of Detection Detection
E. faecalis/total) E. faecalis/total) rate (%), rate (%),
in primary in persistent primary persistent
Study Method N (total) infections infections infection infection OR 95% CI of OR
Guo, 2011 Culture 90 1/45 32/45 2 71 108.31 (13.47–870.68)
Gong, 2012 PCR 60 3/30 16/30 10 53 10.29 (2.56–41.37)
Ozbek, 2009 PCR 79 9/36 32/43 25 74 8.73 (3.15–24.18)
Pirani, 2008 PCR 102 6/79 9/23 8 39 7.82 (2.40–25.47)
Rocas, 2004 PCR 51 7/21 20/30 33 67 4.00 (1.23–13.06)
CI, confidence interval; OR, odds ratio; PCR, polymerase chain reaction.

of calcium hydroxide because of its alkali resistance at a pH of 9.0 to
10.0 (40). A functioning proton pump, which drives protons into the
cell to acidify the cytoplasm, is critical for its survival under a high
pH (41). Microbiota in untreated root canals was mixed (frequently
more than 3 species), comprising gram-negative and gram-positive
and mostly anaerobic microorganisms. In the root canals with persis-
tent infections, facultative anaerobic and gram-positive bacteria are pre-
dominated (13). E. faecalis can colonize root canals in a single
infection (3, 9) and live without deriving nutrients from other
bacteria; this is arguably essential for its establishment in filled root
canals (14). Starved E. faecalis are found to form biofilms through a
harsh environment, and this may contribute to its role in persistent in-
traradicular infections. Starved E. faecalis is more resistant to 5.25%
sodium hypochlorite than those of stationary cells (42). The ability to
invade into dentinal tubules and adhere to collagen in the presence
of human serum might be another superiority that enables the great vi-
tality of E. faecalis (38).
The detection rate of E. faecalis by PCR in primary chronic peri-
apical periodontitis is relatively low; it varies from 8%–33% (5%–82%
in primary infections). In this way, E. faecalis may not be the predom-
inant species in infected canals with chronic periapical periodontitis.
The previous results of the sensitivity analysis and the wide range of
the detection rates in primary infections remind us that the prevalence
of E. faecalis varies in teeth with different forms of pulpal and perira-
dicular diseases. Rocas et al (14) found out that E. faecalis is more
associated with asymptomatic cases than with symptomatic ones in their
study. One possible explanation of the result is that enterococci are
intrinsically not as virulent as other gram-positive organisms (43);
they happen to favor the root canal environment after endodontic treat-
ment but do not appear to participate in the pathogenesis to a large de-
gree. They are more likely to be found in these cases because of their
ability to resist several antimicrobial agents rather than high virulence
(44). E. faecalis was once inoculated into monkey teeth, and only 2
of 9 cases developed radiographically apparent periradicular lesions
(>1 mm) within 6 months (45). Zoletti et al (46) have shown that E.
faecalis is equally present in root canal–treated teeth whether they
have periapical lesions or not. Kaufman et al (47) even found Entero-
coccus spp more frequently in filled canals without radiographic

Figure 3. Detection rates in persistent infections compared with chronic periapical periodontitis. Each block represents a study, with a horizontal line extending
either side of it. The area of the block indicates the weight assigned to that study in the meta-analysis, with the horizontal line depicting the 95% CI. The vertical line
represents no effect. The blue diamond shows the combined results, and the horizontal tips indicate its 95% CI. Diamonds on the right side of the vertical line
indicate that the E. faecalis detection rate of persistent infection is statistically significant higher than that of primary infection.

6 Zhang et al. JOE — Volume -, Number -, - 2015


lesions than their counterparts with lesions. These results support the
assumption that E. faecalis presents in root canals with persistent infec-
tions because of its ability to survive in harsh environments instead of
being the main causation of the lesions. Can E. faecalis be related to
certain forms of pulpal or periradicular lesion or can it be the cause
of certain clinical symptoms? Future studies may try to clarify primary
infections into groups via different forms of pulpal and periapical le-
sions clearly and compare the prevalence of E. faecalis among them.
In conclusion, based on the current evidence, E. faecalis was
more prevalent in persistent intraradicular infections compared with
primary chronic periapical periodontitis.
Acknowledgment
Chenjiao Zhang and Jianrong Du contributed equally to this
study.
The authors deny any conflicts of interest related to this study.
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