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Background  Ag +  and Zn 2+  have already been used in combinations to obtain both enhanced antibacterial effect and low cytotoxicity. Despite this, it is still unclear how the Zn 2+  co-works with Ag +  in the synergistic antibacterial activity. The main purposes of this study were to investigate the co-work pattern and optimum ratio between Ag +  and Zn 2+  in their synergistic antibacterial activity against  E. faecalis , the possible mechanisms behind this synergy and the primary application of optimum Ag + –Zn 2+  co-work pattern against the  E. faecalis  biofilm on dentin. A serial of Ag + –Zn 2+  atomic combination ratios were tested on both planktonic and biofilm-resident  E. faecalis  on dentin, their antibacterial efficiency was calculated and optimum ratio determined. And the cytotoxicity of various Ag + –Zn 2+  atomic ratios was tested on MC3T3-E1 Cells. The role of Zn 2+  in Ag + –Zn 2+ co-work was evaluated using a Zn 2+  pretreatment study and membrane potential—permeability measurement.    Results  The results showed that the synergistically promoted antibacterial effect of Ag + –Zn 2+  combinations was Zn 2+  amount-dependent with the 1:9 and 1:12 Ag + –Zn 2+  atomic ratios showing the most powerful ability against both planktonic and biofilm-resident  E. faecalis.  This co-work could likely be attributed to the depolarization of  E. faecalis  cell membrane by the addition of Zn 2+ . The cytotoxicity of the Ag + –Zn 2+  atomic ratios of 1:9 and 1:12 was much lower than 2% chlorhexidine.    Conclusions  The Ag + –Zn 2+  atomic ratios of 1:9 and 1:12 demonstrated similar strong ability against  E. faecalis  biofilm on dentin but much lower cytotoxicity than 2% chlorhexidine. New medications containing optimum Ag + –Zn 2+  atomic ratios higher than 1:6, such as 1:9 or 1:12, could be developed against  E. faecalis  infection in root canals of teeth or any other parts of human body.

Synergistic mechanism of Ag+–Zn2+ in anti-bacterial activity against Enterococcus faecalis and its application against dentin infection