Overcoming Enterococcus faecalis resistance in endodontics: A review of molecular diagnostics, nanoparticle agents, and emerging photodynamic and phage therapies

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Introduction: Enterococcus faecalis is of clinical importance in root canal infections because it is commonly isolated from persistent infections linked to the failure of endodontic treatment, placing a considerable clinical and financial burden on dental health services. Objective: To review the literature on E. faecalis—specifically its epidemiology, diagnosis, treatment, and oral manifestations—while incorporating recent evidence regarding its involvement in endodontic infections, its persistence, its resistance, and current therapeutic approaches. Methodology: A search of articles published mainly in the last 5 years was carried out using the PubMed, Scopus and Google Scholar databases. The search was implemented using Boolean operators AND, OR, NOT. Keywords used for the search included: “E. faecalis,” “Epidemiology,” “Biofilm,” and “Diagnostic”. Results: Epidemiological analyses reveal a high global prevalence of biofilm-forming E. faecalis (68.68%; 95% CI: 61.33–76.02%), with marked geographic heterogeneity, a substantial burden in systemic infections among patients over 60, and a predominant role in secondary endodontic infections and treatment failure. Molecular diagnostics—PCR, DNA-DNA hybridization, and next-generation sequencing—consistently outperform traditional culture, enhancing sensitivity in persistent infections. Treatment requires multimodal strategies integrating activated irrigation, nanoparticle agents, and emerging photodynamic and phage therapies to overcome intrinsic resistance. Oral manifestations, including chronic periapical lesions, recurrent pain, and rare orbital infections, reflect its persistence and invasive potential, underscoring the need for personalized diagnostic and therapeutic approaches. Conclusion: E. faecalis shows high global prevalence and biofilm-forming capacity, with molecular diagnostics outperforming culture and multimodal therapy—combining activated irrigation, nanoparticles, and emerging approaches—essential to overcome its intrinsic resistance. Its persistence in chronic periapical lesions and invasive potential underscore the need for personalized diagnostic and therapeutic strategies.