Oral Maxillofac Surg
DOI 10.1007/s10006-015-0487-4
ORIGINAL ARTICLE
Oral bacteria adherence to suture threads: an in vitro study
Oswaldo de Castro Costa Neto & Leandro Araujo Lobo &
Natalia Lopes Pontes Iorio & Maria de Fátima Carvalho Vasconcelos &
Lucianne Cople Maia & Patrícia Nivoloni Tannure &
Andréa Gonçalves Antonio
Received: 12 November 2014 / Accepted: 15 February 2015
# Springer-Verlag Berlin Heidelberg 2015
Abstract
Purpose This study investigated the adherence of oral micro-
organisms to different types of suture threads.
Methods Pieces of thread were distributed on 24-well plates,
according to the following groups: (G1) nylon, (G2) silk, (G3)
polyglactin 910, (G4) polyglactin 910 with triclosan. Blank
control (G5) consisted of one thread from each group.
Adherence to thread tests was performed to observe adhesion
of total microorganisms from saliva or two isolates of
Prevotella intermedia (ATCC49046) and Fusobacterium
nucleatum (ATCC51190). Brain-heart infusion (BHI) medium
with or without bacterial inoculum (1.8×107 CFU/mL) was
added to each well of microplates. The microplates were in-
cubated in an anaerobic chamber at 37 °C, for 5 days for
biofilm formation.
Results There was no difference between the groups as regard
to adhesion of F. nucleatum (p>0.05). For P. intermedia, the
threads in G1 and G4 showed a lower level of adhesion
(p<0.05), with no difference between them. Against total mi-
O. de Castro Costa Neto : M. de Fátima Carvalho Vasconcelos :
P. N. Tannure
Department of Post-graduation, Professional Master’s Degree in
Dentistry, School of Dentistry, BUniversidade Veiga de Almeida^,
Rio de Janeiro, Brazil
L. A. Lobo
Department of Medical Microbiology, BInstituto de Microbiologia^,
BUniversidade Federal do Rio de Janeiro^, Rio de Janeiro, Brazil
N. L. P. Iorio
Department of Basic Science, BUniversidade Federal Fluminense^,
Nova Friburgo, Brazil
L. C. Maia : A. G. Antonio (*)
Department Pediatric Dentistry and Orthodontics, School of
Dentistry, BUniversidade Federal do Rio de Janeiro^, Rio de
Janeiro, Brazil
e-mail: andreagantonio@yahoo.com.br
croorganisms, G1 presented a lower level of adherence
(p<0.05), followed by G4; and no difference was observed
between G2 and G3.
Conclusions Total microorganisms and P. intermedia have
different affinities to the tested suture threads, whereas
F. nucleatum presented a similar adherence level. Among
the threads, nylon (G1), followed by polyglactin 910 with
triclosan (G4) presented the lowest microbial adherence level.
Keywords Bacterial adherence . Suture thread . Triclosan .
Prevotella intermedia . Fusobacterium nucleatum
Introduction
Suturing is an essential procedure in dental practice. Dentists
use these procedures in some areas such as Periodontology,
Endodontics, Implant Dentistry, and Oral and Maxillofacial
Surgery. However, suture materials may be considered risk
factors for surgical wound repair, particularly due to the ability
of pathogenic bacteria to adhere to sutures [1] in the form of
biofilm, which may result in infections [2].
These post-operative infections are relatively frequent
complications in oral surgeries, occurring in approximately 2
to 12 % of cases [3, 4]. Among the main bacteria associated
with oral infections, the following aerobic types may be point-
ed out: Streptococcus milleri, Lactobacillus acidophilus, co-
agulase negative Staphylococcus, and the anaerobes, such as
Fusobacterium nucleatum, species of Prevotella, species of
Porphyromonas and Peptostreptococcus spp. [5].
To minimize the occurrence of these infections, the use of
0.12 % chlorhexidine-based antimicrobial mouth washes, as-
sociated with good oral health practice, are among the main
post-operative recommendations [6]. Triclosan is another an-
timicrobial agent commonly used in oral hygiene products,
with proven action against microorganisms resident in the oral

cavity [7]. Recently, an absorbable, multifilament suture
thread treated with triclosan (polyglactin 910 with triclosan)
was shown to be effective in the prevention of colonization of
pathogens associated with non-oral post-operative infections,
such as Staphylococcus aureus and Staphylococcus
epidermidis [8]. However, there is still a scarcity of studies
in the literature, which have investigated the antimicrobial
property of suture threads against opportunist microorganisms
present in the oral cavity, such as the anaerobes
Fusobacterium spp. and Prevotella spp., as well as against a
mixed biofilm. Therefore, the aim of this study was to com-
pare the in vitro adherence of total microorganisms from hu-
man saliva and two isolates: one Fusobacterium nucleatum
and one Prevotella intermedia on different types of suture
threads.
Material and methods
Sample selection
Commercially available suture threads, usually used in oral
surgery, caliber 3-0 presented as follows, were used: (1) nylon
(Ethilon; Ethicon, Inc), a synthetic, nonabsorbable, monofila-
ment thread; (2) silk (Perma-Hand, Ethicon, Inc.), a natural
nonabsorbable, multifilament thread, composed of organic
protein; (3) polyglactin 910 (Vicryl, Ethicon, Inc.), a synthetic,
absorbable, multifilament thread; and (4) polyglactin 910 pre-
viously treated with triclosan (Vicryl Plus, Ethicon, Inc.), also
a synthetic, absorbable, multifilament thread.
Sample preparation for bacterial adherence testing
The suture threads (sterile) were manipulated in a sterile en-
vironment by a single operator. The commercial packaging of
all the threads was opened directly, and threads were cut with a
sterile no. 15 scalpel blade and measured with a sterile
millimetric ruler, resulting in small fragments 1.5 cm long.
After this, the threads were placed in sterile 24-well polysty-
rene plates (TPP, Zellkultur Testplatte 24 F, Switzerland).
Each fragment was inserted into the well, according to the
different test groups (G, n=5 each): G1—nylon (Ethilon);
G2—silk (Perma-Hand); G3—polyglactin 910 (Vicryl);
G4—polyglactin 910, already treated with triclosan (Vicryl
Plus). One thread in each group was used as control (G5, n=
4, blank control).
Bacterial strains, human saliva pool, and preparation
of inoculi
The bacterial samples of F. nucleatum and P. intermedia used
belonged to the culture collection of the Anaerobic
Bacteriology Laboratory of the Department of Medical
Oral Maxillofac Surg
Microbiology of the BInstituto Prof. Paulo de Góes^ at
Federal University of Rio de Janeiro (UFRJ) and were obtain-
ed from the American Type Culture Collection (ATCC):
F. nucleatum (ATCC 51190) and P. intermedia (ATCC
49046).
Before preparing the inoculum, these bacterial strains were
evaluated for purity. After this, isolated bacterial colonies
were selected and transferred to a 0.85 % saline solution, until
turbidity corresponding to 0.5 of the McFarland scale was
obtained (approximately 108 CFU/mL) [9].
In addition to the laboratory strains, a pool of human saliva
was also used, in accordance with the methodology proposed
by Antonio et al. [10]. Thus, unstimulated saliva was collected
from four adult volunteers (two men and two women) who
had fasted for 1 h. These volunteers signed a term of free and
informed consent, authorizing saliva collection. The research
was approved by the Local Research Ethics Committee
(Protocol No. 514.390).
All the volunteers presented a good state of general and
oral health. Thus, 1 mL of unstimulated saliva was col-
lected from each individual in a graded tube, while the
individual were comfortably seated. Their mean whole
saliva flow rate (0.80 mL/min) was registered. The saliva
(1 mL) from each volunteer was placed into a larger tube,
which was mixed using a vortex, resulting in an inoculum
with 2×108 CFU/mL (dilution of 1:200). From this sus-
pension, 0.4×103 CFU/mL of Streptococcus mutans was
identified.
Bacterial adherence test
After the suture threads had been inserted into the polystyrene
microplates (one thread/well, n=20), 100 μL of an inoculum
consisting in 1.8×107 CFU/mL (final concentration) of each
bacterial isolate or total microorganisms from human saliva
resuspended in pre-reduced anaerobically sterilized brain-
heart infusion (BHI) (Difco, Sparks, EUA) was added. Four
other wells received no inoculum or suture threads,
representing the culture medium control. G5, represented by
one suture thread from each group, received culture medium
only, without inoculum. The plates/suture thread system was
incubated in an anaerobic chamber (80 % N2, 10 % CO2, and
10 % H2) at 37 °C for 5 days, in order to allow biofilm to form
on the threads. The experiment was performed in duplicates,
with two plates selected for each inoculum—two for
P. intermedia, two for F. nucleatum, and two for total
microorganisms.
For cell viability, every 48 h after the experiment began, the
culture medium in the wells was renewed (PRAS-BHI, Difco,
100 μL/well). This procedure was always performed after first
removing the existent medium with the use of pipettes, with-
out allowing the tips to touch the threads.
Oral Maxillofac Surg
Microbiologic analysis of adherence of specific and mixed
microorganisms to the suture threads
After an experimental time interval of 5 days, the media was
removed and the wells gently washed with sterile saline solu-
tion (1000 μL/three times). After this, the suture threads were
removed with the aid of sterile cotton wool forceps and were
inserted into tubes containing 1 mL of saline solution (one
thread/tube). Right after this, the tube/thread system was
vortexed for 30 s in order to detach the biofilm/cells adhered
to the thread. Aliquots of 50 μL were collected from this
suspension for colony counts (dilutions from 10−1 to 10−3),
in triplicate, in CDC anaerobe blood agar (5 % sheep blood,
400 μg/mL cysteine, 5 μg/mL hemin, and 1 μg/mL vitamin
K) in order to perform specific microorganism counts
(F. nucleatum and P. intermedia) and total microorganisms
(obtained from the pooled saliva) counts. The plates were then
incubated at 37 °C for 48 h in the anaerobic chamber as de-
scribed, and the results of adherence were express in CFU/mL.
Analysis of suture threads by scanning electron microscopy
(SEM)
A thread from each group, as well as the threads from G5, was
submitted to analysis by scanning electron microscopy (SEM)
at the Hertha Meyer Cellular Ultrastructure Laboratory, of the
UFRJ. The different suture materials were sputter coated
(Balzers model FL 9496) with gold (layer of 2 nm). After this,
the samples were visualized with a scanning electron micro-
scope (JSM 5310, Jeol, Japan) with a voltage of 15 kV, at
1000× magnification. The aim of this analysis was to confirm
the presence of bacterial colonies adhered to the different su-
ture threads, according to the groups studied, and compare
them with the threads that represented the blank control.
Statistical data analysis
The results were saved in a database of the statistical software
program SPSS version 20.0. The Shapiro-Wilk test was used
to verify the normal distribution of the microbiologic results.
To evaluate the statistical significance of the bacterial adher-
ence values, ANOVA and subsequently the Tukey tests were
used. For all analyses, differences between means were con-
sidered significantly different when values of p<0.05 were
obtained.
Results
Sterility of the threads and media used was proved by means
of the control groups, in which no turbidity or change in color
of the wells were observed. Microbial adherence was ob-
served in photomicrographs (Fig. 1).
When the different suture threads and different microor-
ganisms studied were compared among them, we observed
that P. intermedia was the microorganism with the highest
level of adherence among all the threads (p<0.05) (Table 1).
To analyze the effect of the type of thread on bacterial
adhesion, considering each microorganism analyzed, the
polyglactin 910 thread with triclosan (Vicryl Plus®) (G4)
was compared with the others: nylon monofilament
(Ethilon®) (G1) and multifilament types, silk (Perma-
Hand®) (G2), and polyglactin 910 without triclosan
(Vicryl®) (G3). No difference in adherence of F. nucleatum
was observed among the studied groups (p>0.05). Whereas
the adherence of P. intermedia, groups G1 and G4 presented a
lower count of the above-mentioned microorganism (6.09×
105 ±0.10×105; 5.47×105 ±0.09×105; respectively), with the
difference found being significant only when compared with
groups G2 (7.17×105 ±0.28×105) and G3 (6.56×105 ±0.44×
105) (Table 1).
In the total microorganism count, there was a lower level of
adherence (p<0.05) in groups G1 (0.34×105 ±0.6×105) and
G4 (0.85×105 ±0.03×105), when compared with groups G2
(1.90 × 10 5 ± 0.07 × 10 5 ) and G3 (1.49 × 10 5 ± 0.18 × 10 5 ).
However, a lower number of microorganisms was observed
in group G1 (p<0.05) (Table 1).
Discussion
The choice of which type of suture thread to use is subject to
diverse criteria, which include tensile strength, knot stability,
minimum tissue trauma, elasticity and plasticity, time of ab-
sorption, absence of allergenic properties, and low adhesion of
microorganisms [11]. Bacterial adhesion to synthetic materials
such as suture threads, prostheses, and grafts have been the
objects of study of many researchers [1, 11–13]. In the present
research, a higher level of microbial adherence was observed
to braided threads (G2, G3, and G4), in agreement with pre-
vious studies [11, 12]. Nevertheless, statistical differences
were observed between the braided threads studied, which
demonstrates that there are other factors, such as the type of
material made to manufacture them and their composition, in
addition to the tridimensional disposition of the thread may
have an influence on bacterial adhesion.
This may be noted, particularly with the braided silk
threads (G2). Although these threads represent a category of
natural, nonabsorbable threads widely used in oral surgery and
also indicated as the first choice material because they are easy
to use, present knot strength, relatively low inflammatory re-
sponse (when compared with other natural threads), comfort,
and low cost [14], the authors observed that this group (G2)
presented the highest level of bacterial colonization.
It is known that the biofilm formed on sutures may act as a
focus of infection and create a potential risk to wound healing
 Oral Maxillofac Surg

Fig. 1 Photomicrographs of the

threads studied (1—nylon, G1;
2—silk, G2; 3—polyglactin 910;
4—polyglactin 910 with
triclosan, G4) according to the
presence of each microorganism
analyzed: A—total
microorganisms, B—Prevotella
intermedia; C—Fusobacterium
nucleatum), or absence D—
controls (G5). Magnification of
1000×

[13]. Furthermore, threads that induce a higher inflammatory
response tend to cause greater erythema and edema at wound
margins, which may cause dehiscence and opening of sutures
[15]. Therefore, efforts have been made to minimize bacterial
adhesion to threads by the concomitant use of antimicrobial
agents, particularly chlorhexidine [13].
Considering that in spite of this antimicrobial agent being
widely used [16] and having a broad spectrum against many
oral pathogens [17], Horner et al. have demonstrated that the
indiscriminate use of chlorhexidine has increased the resis-
tance of microorganisms [18]. Thus, other antimicrobial
agents have been tested, with special attention to triclosan,
because it is present in dental products such as dentifrices
and mouth washes. Moreover, this compound has been incor-
porated into a polyglactin suture thread [8, 19, 20], therefore
being the object of study of the present research.
Previous studies [11, 13, 21] that have invested the adher-
ence of microorganisms to a certain suture thread, with and
without treatment with triclosan, observed no difference in
bacterial colonization. However, recent systematic reviews
have found significant reductions of up to 3 % in post-
operative infection rates when threads covered with triclosan
were used [22–24].
In the present study, it was demonstrated that group G4
(polyglactin 910 with triclosan incorporated) presented lower
adherence of P. intermedia and total microorganisms when

Table 1 Correlation of microbial adherence values between the different types of suture threads studied

Thread Fusobacterium nucleatum (Mean/SD) Prevotella intermedia (Mean/SD) Total microorganisms (Mean/SD)

G1—Nylon 1.64×105 ±0.48×105a,A 6.09×105 ±0.10×105a,B 0.34×105 ±0.06×105a,A

G2—Silk 1.70×105 ±0.21×105a,A 7.17×105 ±0.28×105a,B 1.9×105 ±0.07×105b,A
G3—Polyglactin 910 2.01×105 ±0.21×105a,A 6.56×105 ±0.44×105b,B 1.49×105 ±0.18×105b,A
G4—Polyglactin 910 with triclosan 1.9×105 ±0.19×105a,A 5.47×105 ±0.09×105a,B 0.85×105 ±0.03×105c,A

Different lowercase letters differ statistically between them, when the different groups were compared, within each column of microorganisms studied
(Tukey test p<0.05). Different capital letters differ statistically between them, when the different groups were compared, within each line, considering
the different microorganisms. Values expressed in colony forming units per milliliter (CFU/mL)
SD standard deviation
Oral Maxillofac Surg
compared with the same type of thread (polyglactin 910) with-
out triclosan incorporated, corroborating the findings of pre-
vious studies [22–24]. Researches in vivo have demonstrated
that the efficacy of triclosan alone, or as a mouth wash, is
limited by its low substantivity, that is, acts for a short time
and is rapidly eliminated from the oral cavity [25, 26].
Whereas, when this compound is incorporated into suture
thread, the time of action against microorganisms is probably
extended, thereby increasing its substantivity. Edmiston et al.
also demonstrated favorable results as regards the adhesion of
S. aureus, S. epidermidis, and Escherichia coli to threads im-
pregnated with triclosan (Vicryl Plus®), when compared with
the same thread without triclosan [20]. However, it should be
emphasized that this study [20] was conducted with bacteria
of the oral cavity itself, differently from the present study.
We performed adherence tests with biofilm, using micro-
organisms present in saliva, in periodontal biofilm and fre-
quently found in maxillofacial infections and bacterial endo-
carditis [1, 2, 27–29]. In the tests performed with
F. nucleatum, there were no significant differences between
the studied threads. Even nylon tended to present a lower
quantity of adhered cells, and this result was not significant.
It is suggested that the characteristics of adherence of
the species of Fusobacterium isolated, as observed in
this study, were different from those in a mixed biofilm.
In mixed biofilm, due to presenting at least three differ-
ent molecules of multifunctional adhesins, F. nucleatum
is essential in the co-aggregation of other bacteria,
playing a role of transitional organism in the develop-
ment of dental biofilm. Thus, for this specific bacteria,
the absence of other biofilm microorganisms may have
influenced the results [30, 31].
Group G4 (polyglactin 910 with triclosan) presented a low-
er number of adhered colonies of P. intermedia when com-
pared with G2 and G3, however, without statistical difference
in comparison with G1. These results of Vicryl Plus® may be
associated with the good efficiency of triclosan against the
Prevotella species. According to McBain et al., P. nigrescens
is classified as being highly susceptible to triclosan [32].
Nudera et al. also observed great effectiveness of triclosan
against five pathogens, among them P. intermedia [33].
Group G1 (nylon) was the group that presented the most
promising results, particularly with regard to total microorgan-
isms, because a significantly lower colony count was observed
in this studied group. The authors suggest that these results are
due to the fact that it was the only monofilament thread tested,
and it therefore presented a lower contact surface. However, as
previously reported, this characteristic is not the only variable
that influences a lower level of microbial adherence, because
the type of material and diameter must also be considered. In
our study, as threads of equal diameter (3-0) and from the
same manufacturer were used, the variables that possibly in-
fluence this aspect of adherence were the type of filament
(monofilament×multifilament) and the material of which the
thread was made.
Even in view of this favorable result of G2 compared with
G4, considering total microorganisms, it is worth pointing out
that the thread with triclosan presents all the advantages of a
multifilament thread when compared with nylon (monofila-
ment), such as tensile strength, knot safety, ease of manipula-
tion, and comfort. Therefore, although this was an in vitro
study, we believe that the thread with triclosan (polyglactin
910 with triclosan) presents favorable characteristics for use in
surgeries [14, 15] in spite of its higher cost. Nevertheless, the
authors suggest that further studies should be conducted, es-
pecially clinical studies to prove the effectiveness of Vicryl
thread with triclosan and its in vivo behavior, when compared
with nylon thread.
Conclusion
This study showed that different species of bacteria adhere
with a different degree of affinity to suture threads. Nylon
and polyglactin 910 thread with triclosan showed a lower level
of microorganism adherence to their structure, with the advan-
tage of nylon over polyglactin 910 with triclosan®, consider-
ing total microorganisms.
Acknowledgments The authors wish to thank FAPERJ for the finan-
cial support provided to conduct this study. Also, we are grateful to
Karine Caldas Pinto for her technical support.
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