Antibiotic resistance and herbal alternatives in endodontics: mechanisms, evidence, and clinical outcomes

Antibiotic resistance in endodontic infections, specifically those caused by Enterococcus faecalis biofilms, limits the efficacy of conventional disinfection methods. This review examines the use of herbal agents, including Triphala, green tea polyphenols, neem, Morinda citrifolia, curcumin, and acemannan, as biologically active and safe options in root canal therapy. These plant compounds act through multiple mechanisms, including membrane disruption, inhibition of quorum sensing, antioxidant activity, and control of inflammation while also promoting the repair of dentin and pulp. Findings from in vitro, ex vivo, and small clinical studies demonstrate antimicrobial effects comparable to those of sodium hypochlorite and chlorhexidine, with lower cytotoxicity and improved tissue compatibility. Herbal agents are also practical in low-resource settings because they are affordable, stable, and readily available. However, inconsistent extraction methods, nonstandardised formulations, and limited large-scale clinical data restrict their clinical use. This review summarises the available evidence on the mechanisms, efficacy, safety, and clinical relevance of herbal agents in endodontics and outlines the research needs for their application in routine practice.