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CRITICAL REVIEWS IN ORAL BIOLOGY & MEDICINE

N. Takahashi1* and B. Nyvad2
1

Division of Oral Ecology and Biochemistry, Department of Oral Biology, Tohoku University Graduate School of Dentistry, 4–1 Seiryo-machi, Aoba-ku, Sendai, 980–8575, Japan; and 2 School of Dentistry, Faculty of Health Sciences, University of Aarhus, Denmark; *corresponding author, nobu-t@mail.tains .tohoku.ac.jp J Dent Res 90(3):294-303, 2011

The Role of Bacteria in the Caries Process: Ecological Perspectives

ABSTRACT
Dental biofilms produce acids from carbohydrates that result in caries. According to the extended caries ecological hypothesis, the caries process consists of 3 reversible stages. The microflora on clinically sound enamel surfaces contains mainly non-mutans streptococci and Actinomyces, in which acidification is mild and infrequent. This is compatible with equilibrium of the demineralization/ remineralization balance or shifts the mineral balance toward net mineral gain (dynamic stability stage). When sugar is supplied frequently, acidification becomes moderate and frequent. This may enhance the acidogenicity and acidurance of the non-mutans bacteria adaptively. In addition, more aciduric strains, such as ‘low-pH’ non-mutans streptococci, may increase selectively. These microbial acid-induced adaptation and selection processes may, over time, shift the demineralization/ remineralization balance toward net mineral loss, leading to initiation/progression of dental caries (acidogenic stage). Under severe and prolonged acidic conditions, more aciduric bacteria become dominant through acid-induced selection by temporary acid-impairment and acid-inhibition of growth (aciduric stage). At this stage, mutans streptococci and lactobacilli as well as aciduric strains of non-mutans streptococci, Actinomyces, bifidobacteria, and yeasts may become dominant. Many acidogenic and aciduric bacteria are involved in caries. Environmental acidification is the main determinant of the phenotypic and genotypic changes that occur in the microflora during caries.

INTRODuCTION

T

KEY WORDS: acidogenicity, acidurance, acidinduced adaptation, acid-induced selection, Actinomyces, Bifidobacterium, caries-associated bacteria, caries process, extended caries ecological hypothesis, Lactobacillus, mutans streptococci, non-mutans streptococci.
DOI: 10.1177/0022034510379602 Received February 17, 2010; Last revision June 22, 2010; Accepted July 2, 2010 © International & American Associations for Dental Research

he supragingival dental biofilm constitutes an ecosystem of bacteria that exhibits a variety of physiological characteristics. In particular, the acid production resulting from carbohydrate metabolism by these bacteria and the subsequent decrease in environmental pH are responsible for the demineralization of tooth surfaces (Marsh and Nyvad, 2008). However, other physiological traits of the biofilm bacteria, such as base formation, may partly dampen the demineralization processes. Therefore, Kleinberg (2002) suggested that it is the proportions and numbers of acid-base-producing bacteria that are the core of dental caries activity. Much research has identified mutans streptococci (MS) as the major pathogens of dental caries. This is because, first, MS are frequently isolated from cavitated caries lesions; second, MS induce caries formation in animals fed a sucrose-rich diet; third, MS are highly acidogenic and aciduric (Hamada and Slade, 1980; Loesche, 1986); and fourth, MS are able to produce surface antigens I/II and water-insoluble glucan, which promote bacterial adhesion to the tooth surface and to other bacteria (Hamada and Slade, 1980). A systematic literature review by Tanzer et al. (2001) confirms a central role for the MS in the initiation of dental caries on enamel and root surfaces. However, several well-designed studies have revealed that the level of MS is not necessarily high in caries-associated biofilms, especially the microflora associated with non-cavitated stages of lesion formation (van Houte et al., 1991a; Sansone et al., 1993). Instead, it is proposed that non-mutans acidogenic and aciduric bacteria, including non-mutans streptococci and Actinomyces (Sansone et al., 1993; van Houte, 1994; van Houte et al., 1996), are more closely involved with the initiation of caries. In addition, van Ruyven et al. (2000) have detected non-mutans aciduric bacteria other than non-mutans streptococci and Actinomyces from dental biofilms covering white-spot lesions. They found that these bacteria consisted of various species, including lactobacilli and Bifidobacterium. Given these circumstances, the authors reconsidered the caries process from a microbiological, biochemical, ecological, and clinical perspective, and proposed an extension of the ecological plaque hypothesis (Takahashi and Nyvad, 2008) to explain the relation between dynamic changes in the phenotypic/genotypic properties of plaque bacteria and the demineralization/ remineralization balance of the caries process (Fig. 1). In this hypothesis, dental plaque is a dynamic microbial ecosystem in which non-mutans bacteria (mainly non-mutans streptococci and Actinomyces) are the key players for maintaining dynamic stability, i.e., a natural pH cycle (dynamic stability stage). Microbial acid-induced adaptation and subsequent acid-induced selection of ‘low-pH’ non-mutans bacteria play a critical role in destabilizing the homeostasis of the plaque by facilitating a shift of the demineralization/ remineralization balance from ‘net mineral gain’ to ‘net mineral loss’ (acidogenic stage). Once the acidic environment has been established, MS and other

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2005. and re-assess the role of these absence of MS and lactobacilli. likely play important roles in the predominant genera in mature smooth-surface plaque therefore caries process. mitis 1 (Nyvad and Aas et al. In the present artithe major bacterial group in white spots (Sansone et al. Prevotellae. 1987).. . and S. tion methods have also revealed that the microflora of clinically These bacteria. Mantzourani et al. produced by members of the early microflora.. 2009). are sound and carious surfaces is much more diverse and comprises often referred to as the ‘non-mutans streptococci’. 2005. WhITE-SPOT MS are encountered less frequently at the advancing front of LESIONS. Chhour et al. dental diseases may be considered a model system of amphibiosis (Ruby and Goldner. MS comtooth surface changes with caries lesion development.. Surprisingly. 2008). of which 50-60% are not culgenetically distinct from the MS that belong to the ‘mutans group’ tivable (Aas et al. dominance of non-mutans streptococci and Actinomyces to regardless of the caries activity of the individual (Nyvad and dominance of MS and other non-mutans bacteria. Under ‘normal’ conditions. 1981). 1995). from prise only 2% or less of the initial streptococcal population. The caries process according to an extended caries ecological hypothesis (modified from relationship with the host. versa (Stanier et al. acterized by mutualism (beneficial to both). AND CAVITATED DENTIN LESIONS dentin caries. 2007).. 2008. MS are present ism (beneficial to one and detrimental to the other) and vice in very low numbers (Bowden et al. Boue et al. 1994. and is congruent with the ecological caries hypothesis Houte et al.. 1984. including rampant caries. Propionibacterium.. 2009a). oralis. 1987). van Palenstein Helderman. 2000). suggesting that MS are associated with progressive stages of caries. the composition suggest... However. 1989). charTakahashi and Nyvad. these studies (Kawamura et al.. Recent molecular identificaity of the early colonizers on teeth belong to the ‘mitis group’. MICROfLORA Of DENTAL PLAquE ON CLINICALLY Milnes and Bowden. 2004. in the about caries-associated bacteria. e. most of which are nontions in a reciprocal manner. mutans. sanguinis.g. including Kilian. 1974. 1970). In fact. and Bifidobacterium Studies have shown that the initial colonizers of newly cleaned are more prevalent (Edwardsson.. Yet. Takahashi and Nyvad. the dissolution of enamel can be bacteria in the caries process from an ecological perspective. mainly S.J Dent Res 90(3) 2011 Caries-associated Bacteria in the Caries Process 295 aciduric bacteria may increase and promote lesion development by sustaining an environment characterized by ‘net mineral loss’ (aciduric stage). and Actinomyces. cle. The streptococci. the nature of a particular symbiosis may shift under changing condibelong to Actinomyces and Streptococcus. 1985. tooth surfaces constitute a highly selected part of the oral microMartin et al. Dige et al. 1990). As the microflora ages.. 2008)... such as Actinomyces. Munson et al. again... Nevertheless. MS BACTERIAL MEMBERS IN ThE CARIES PROCESS: constitute about 30% of the total flora (Loesche et al. a term invented by the microbial ecologist Theodore Rosebury about 50 years ago (Rosebury. This dynamic adaptation is the basic The proportion of MS in plaque covering white-spot enamel principle of endogenous disease processes. Bifidobacterium. flora. From the perspective of microbial ecology. 2004. In cavitated lesions in dentin. are also All these findings clearly show that the microflora on the present (Li et al. with mutualism becoming parasitmutans streptococci (Ximénez-Fyvie et al. 1978. Becker et al. 1996). where lactobacilli. 2002. shifts from Streptococcus-dominant to Actinomyces-dominant Lactobacillus. S.. These observations emphasize that the vast majorlactobacilli and Bifidobacterium... that bacterial species other than S.. Amphibiosis is the dynamic adaptation that occurs in response to changing environmental conditions between two dissimilar organisms living together. Kilian. the authors will focus on recent microbiological findings van Houte et al. 1991b). 2008). exclusively (Boyar et al. which are hundreds of predominant species. but other genera. as well as other viridans group streptococci. 1975). 2002. By contrast. 1962).. including dental carlesions is often higher than that at clinically healthy sites (van ies. 1993. SOuND ENAMEL SuRfACES. micro-organisms in the oral cavity live in a symbiotic figure 1. it has been shown that. non-mutans streptococci still remain (Marsh. non-mutans (Syed and Loesche.

1999) may easily restore the mineral balance toward net mineral gain in favor of ‘remineralization’ (Manji et al. acting as phosphoryl donors instead of ATP. lactobacilli. 1998) revealed that 10 times the daily glucose supply (glucose pulse) at pH 7. 1998. In general. except for regular mealtimes.0 established a stable microbial composition characterized by dominance of non-mutans streptococci and Actinomyces. as occurs between meals. In addition. 1997). . where salivary glycoproteins are always available. supporting their co-existence with other bacteria in a nutritionally fluctuating environment. Streptococcus mitis.. BACTERIAL METABOLIC PROPERTIES RELEVANT TO CARIES AND SuRVIVAL IN ThE ORAL CAVITY Most bacteria in supragingival plaque metabolize various sugars and produce acids through a common glycolytic pathway. 2005) that can liberate sugars and amino-sugars from glycoproteins such as the mucin contained in saliva. as in the oral cavity between meals. but also to survive under the acidic conditions in the oral cavity. which resembles that of oral biofilms on clinically sound enamel surfaces (Fig. and the acids can demineralize the dental hard tissues. 1996). However. 1994). Komiyama et al.3-5.4 3. It should be realized... except that fucosidase activity has been shown in Lactobacillus rhamnosus (Bradshaw et al. In the chemostat. and they can utilize the IPS as an energy source to produce acids when sugar is limited.. however. when grown or incubated with glucose. on the basis of final pH values.. this metabolic pathway produces alkali and neutralizes the intracellular and the environmental pH (Burne and Marquis. 1990.. 1999). resulting in mild and low frequencies of acidification (dynamic stability stage. 1996. A chemostat study with 9 representative oral bacterial strains (Bradshaw and Marsh.. the ‘critical’ pH for the demineralization of enamel. most non-mutans streptococci can utilize arginine/argininecontaining peptides available in saliva through the arginine deiminase system. if the acidification episodes are mild and infrequent... ThE ROLE Of CARIES-RELATED BACTERIA IN ThE CARIES PROCESS ACCORDING TO ThE ExTENDED CARIES ECOLOGICAL hYPOThESIS Dynamic Stability Stage Many micro-organisms in dental plaque formed on clinically sound surfaces can produce acids from sugary foods. 1994). This is an advantage for non-mutans streptococci and Actinomyces to survive in the oral cavity. are shown in the Table (Holt. 1983. homeostatic mechanisms in the plaque (Marsh and Martin. a highenergy phosphoryl-bond-containing by-product from the metabolism of polymers such as nucleic acids and glycogens. sugar is always limited in the oral cavity (Carlsson. can store the extra sugars as intracellular polysaccharides (IPS). 3 Haukioja et al. in which they utilize high-energy polyphosphate and pyrophosphate compounds for synthesis of hexokinase and phosphofructokinase.2-5.. 2A). 1970. 1976. This means that the Actinomyces are able to exploit a surplus ATP to synthesize polyphosphate as an energy reservoir. 1990. lactobacilli. the growth medium contained a relatively high level of hog gastric mucin and a limited level of glucose. 2006) and can utilize lactic acid as a carbon source for growth (Takahashi and Yamada. and a glucose pulse gave a temporary increase of glucose in the environment. 2008). However. 1988). Final pH when incubated in glucose solution. which degrades the arginine molecule to ammonia and carbon dioxide with production of ATP.6-4.0 a Reference 1 2 1 1 3 a a a b Final pH when grown in batch culture containing glucose. Acidogenicity of Representative Caries-associated Bacteria Bacteria Non-mutans streptococci Actinomyces Mutans streptococci Lactobacillus Bifidobacterium a b Final pH 4. 1990.0 3.. MS. and Actinomyces naeslundii (Beighton and Whiley. 1995). along with dietary sugars provided at infrequent meals. and Bifidobacterium. Both non-mutans streptococci and Actinomyces have an ability to utilize glycoproteins and amino acids supplied continuously in saliva.0-4.. Whiley and Beighton. 1991) and Actinomyces (Hamilton and Ellwood. oral streptococci. 2 Johnson et al. Actinomyces. including Streptococcus oralis. 1984. oralis also expresses N-acetyl-β-D-glucosaminidase and β-D-galactosidase. 1990. 1). 1984.. mannosidase production has been identified within the viridans group streptococci (Homer et al.5. 2002. The Actinomyces have a unique glycolytic system (Takahashi et al. These diverse physiological characteristics of Actinomyces seem to be advantageous to survival and domination in supragingival plaque (Takahashi and Yamada. The final pH values of non-mutans streptococci. and all non-mutans streptococci grow on amino-sugars (Byers et al. that the final pH values of nonmutans streptococci and Actinomyces can be lower than pH 5. The arginine deiminase system is helpful for non-mutans streptococci not only to utilize arginine as an energy source. S. 1998). 1999b). most MS and lactobacilli do not have these metabolic features. Fig. non-mutans streptococci and Actinomyces have a variety of extracellular glycosidases (Schaal. This dynamic environment brings the microflora to a stable stage. Takahashi et al. and Bifidobacterium are more acidogenic and aciduric than non-mutans streptococci and Actinomyces. including MS and non-mutans streptococci (van Houte et al. Paddick et al. When sugar is supplied in excess.2 4. the Embden-Meyerhof-Parnas pathway. Whiley and Beighton. In a person with healthy eating habits. 1984. 2008. the Actinomyces are often ureolytic (Kleinberg. In addition.9-4. Liu et al. Beighton and Whiley.. Fig.7 4. Studies have identified sialidases in many species. and salvage energy from pyrophosphate.. Bradshaw et al. Overall.296 Takahashi & Nyvad J Dent Res 90(3) 2011 Table. in addition to α-1-fucosidase and mannosidase activity (Byers et al.. MS. Furthermore. Hamilton. 1991). respectively. which mimics mealtimes. Haukioja et al. 1 Holt. 1). Johnson et al. with dominance of non-mutans streptococci and Actinomyces (dynamic stability stage. Furthermore. 2001). 2000).

Bacteria were grown at various pH values with pH control by the periodic vested. Microbial acid-induced adaptation (phenotypic 7. the increase in activities of H -ATPase and arginine deimiAlthough ‘low-pH’ non-mutans bacteria can increase their nase and expression of stress proteins (homologues of heat-shock acidurance and acidogenicity. and 2 strains of Actinomyces.5 hrs. The bacteria were then harby Horiuchi et al. Following a rapid exposure to pH 4.. 4. Chemostat culture 40 L. Data with glucose. but (genotypic change of the microflora) will cause a shift in the after pre-acidification at pH 5. and and 1. This change in the streptococci Lactobacillus environment may enhance the acidogenicity and acidurance of 10 0.0 5. and the final pH are given by means of 2 strains of MS.5 for 0.3 30 quently or salivary secretion is S. Fusobacterium nucleatum) are omitted. Hsp60 and Hsp70) were observed following incubation at in supragingival plaque.33) ment. (2009).96-4. 4A) (Horiuchi et al. (3) induction of the arginine deiminase Aciduric Stage system that produces alkali from arginine or arginine-containing Acid-induced Selection of Aciduric Bacteria peptides.19 after 1991b. MS and lactobacilli are more competipH 5. Bacteria initially grown at pH environment. Fig.12 and pH 3. modified from the data by Bradshaw and Marsh (1998). when intake or poor salivary secretion can be a driving force to non-mutans streptococci and Actinomyces initially treated at pH enhance the acidogenicity and acidurance of the non-mutans 4.5. and take over the dominant position protein. 1). 3).0 were killed by acid stress in a strain-dependent manner followchange of the microflora) as well as acid-induced selection ing exposure to pH 4. modified from the data 3). (Panel B) Results of batch culture study. The biochemical mechademineralization/remineralization balance is disturbed over an nisms underlying the acid-induced adaptation are thought to extended period of time.0. i. will increase selectively in this their acidurance adaptively (Fig.4 Mutans streptococci When sugar is supplied fre0.5. 1996) that the population of more aciduric strains.90-4. and S. rhamnosus 297 B. all the bacteria increased acidogenic potential of the microflora.04-4. 1.1 the non-mutans bacteria adapA. but after incubation at pH 5. tive under severely acidic conditions.4-81%). they started to Growth rate Microbial proportion (%) . Veillonella dispar.24 after 0. resulting in establishment of a more acidic environacidogenicity expressed as final pH values varied (pH 4.2 20 the plaque become more severe S. (Panel A) Results of acidogenicity. 1.5 (Takahashi and Yamada.0 4.0. and incubated addition of alkaline. mutans 0. respectively). These bacteria chemostat study. all the bacteria increased their acidogenicity so heterogeneous with respect to acidurance (van Houte et al. 2 strains of non-mutans streptococci. Growth ability at different pH values of representative oral bacteria.. Furthermore. they increased their figure 2. values were measured as a marker of acidogenicity. These bacteria were also able to increase ‘low-pH’ non-mutans bacteria. naeslundii Actinomyces tively. respectively (Fig. 2000): (1) an dental caries (acidogenic stage.5 for 1 hr. gordonii. S. increase in proton impermeability of the cell membrane. sanguinis.0 4.0 for 1 hr (survival rate: 0. (2) induction of proton-translocating ATPase (H+-ATPase) activity that expels proton from cells. mitis. 1999a). Prevotella nigrescens. provided the their acidurance (survival rate: 0. (pH 3. which. non-mutans bacwithout incubation at pH 5. gordonii non-mutans and frequent.5 for teria such as non-mutans streptococci and Actinomyces are still 0.0 S.5 hr. 1. The culture pH was allowed were grown first at pH 7..0-4.93-4. the pH decreases in S. non-mutans streptococci and Actinomyces parBacteria: Genotypic Change of Microflora tially lost their viability. panel. pH 3. and 1. Their bacteria. and (4) induction of stress proteins that protect enzymes by Temporary Acid-impairment and nucleic acids from acid denaturation.5 5. washed.J Dent Res 90(3) 2011 Acidogenic Stage Acid-induced Adaptation: Phenotypic Changes of Microflora Caries-associated Bacteria in the Caries Process A. 2009). and to fall to either a preset value of 7. Even if acid-induced adaptation occurs. as often observed in mature dental plaque after a Acid-induced Selection of ‘Low-ph’ Non-mutans sugar exposure..5 or without pH control.5 5. Takahashi and Yamada (1999a) have shown that when non-mutans streptococci.5 hrs. and bacterial growth rates were calculated from the logarithmic growth phase.e.5 hrs. Five bacterial strains are shown in the afterward at pH 5. oralis.0.0009-71%). Batch culture 0. may lead to initiation/progression of involve the following mechanisms (Quivey et al. 0 0 including S. oralis too scarce to neutralize the acids produced.0 in growth media were returned to pH 7. were without control pH pH exposed to an acidic environment.5. In non-mutans strepto+ cocci. while the other 4 strains (Neisserria subflava. while MS and lactobacilli were able to Acidification of dental plaque microflora due to frequent sugar survive (Fig.5 7.

When pH was further allowed to fall to 4. and that the acid-impaired bacteria need a considerable time to recover their growth ability. The basic biochemical reactions in response to acid stress are therefore similar to those described above in the acidogenic stage. Since Bifidobacterium is also acidogenic and aciduric.. at pH ≤ 5. It should be noted that some nonmutans streptococci and Actinomyces strains did not start to grow by 10 hrs after a two-hour acidification. (Panel A) Acidogenicity (final pH values) after acidification at pH 5. 1).83). Svensäter et al. In its less severe stage. Under these conditions. and their proportion of the microflora was high (van Houte et al. acid-induced adaptation may still occur in aciduric bacteria. and ranged from 0. MS and lactobacilli became dominant. lactobacilli grew faster than MS. This may be the reason MS and lactobacilli are frequently isolated from established carious cavities. At the aciduric stage. will be eliminated and replaced by more aciduric bacteria. Milnes and Bowden. ECC is characterized by smoothsurface lesions of the primary teeth and is called ‘rampant caries’ (Milnes. Delay of the growth after acidification was common among non-mutans streptococci and Actinomyces. (1997) have shown that a transient acidification temporarily inactivated the glycolytic enzymes. as shown in the Table. 2008).0) after acidification at pH 5. 1991. ECC can destroy the primary dentition of toddlers and small children. Hojo et al. However.1 0.41< hr after two-hour acidification. prolonged acidic conditions (pH ≤ 5) can occur in carious cavities (Dirksen et al.51 hrs after 0. similar to lactobacilli and more so than MS (van Houte CLINICAL MICROBIOLOGICAL OBSERVATIONS IN SuPPORT Of ThE ExTENDED ECOLOGICAL CARIES hYPOThESIS Early Childhood Caries (ECC) and MS: Which Comes first.5 hr 2. 1990. 2B). The data were modified from Takahashi and Yamada (1999).6.01 0. 4A).00 to 1. the MS or Poor Eating habits/Low Socio-economic Status? ECC refers to any dental caries in the primary dentition.0 B 3.. from 1. it has been reported that both the detection frequency of MS in saliva and the proportion of MS in plaque were associated with the severity . 1997). such as MS and lactobacilli (aciduric stage. probably except for some aciduric strains of nonmutans streptococci and Actinomyces (Nyvad and Kilian. such as MS and lactobacilli (Belli and Marquis.. Given these observations. 1982. non-mutans streptococci and Actinomyces. 4B) (Horiuchi et al. and learning and speech problems (AAPD. Acid-induced adaptation of non-mutans streptococci. 2008). it is suggested that prolonged acidic conditions around pH 5 may cause the emergence of MS and lactobacilli in the microbial flora..5-hour acidification. they may also overcome the competition and increase their proportion of the microflora. MS and lactobacilli increased dramatically. where clearance of acids is disturbed. 4. indicating that they required a considerable time for growth to start again.5. MS and lactobacilli were able to grow faster than non-mutans streptococci and Actinomyces (Fig.44 hrs after one-hour acidification. Takahashi et al. It is noticeable that all caries lesions with pH < 5 were designated as ‘active’ lesions and contained lactic acid exclusively (Hojo et al. which returned to original levels after the pH had returned to neutral.8 100 10 Viability (%) 1 0. 1994). consistent with the chemostat results that the proportion of lactobacilli became higher than that of MS at pH ≤ 4. 1994). 1996. acid-induced selection by acid-impairment and growth competition are the major reasons for the shift in the composition of the microflora. 1985). 1996).0 hr 1.4 0 hr 0. it can lead to pain. In the oral cavity. 2009).54 to 2. 1962. 2A). However. 4.298 A Final pH after addition of glucose Takahashi & Nyvad J Dent Res 90(3) 2011 4.5.2 Acid-induced Selection of Aciduric Bacteria by Prolonged Acidification A chemostat experiment with 9 representative oral bacteria (Bradshaw and Marsh.. 2009).5 and without control (final pH = 3. leading to a pronounced net mineral loss and rapid lesion progression. In addition. although the mechanisms have not yet been clarified. the MS have been frequently isolated. and. Haukioja et al. Fig. Aas et al. the bacterial growth (actual growth curve) was much slower than that expected from the number of surviving bacterial cells (expected growth curve) (Fig.. if left untreated. Ma et al. At pH ≤ 4. No viability loss and delay were observed in MS and lactobacilli.001 figure 3.. nutritional insufficiencies. 1998) showed that when the pH was allowed to fall to a preset value of 5. (Panel B) Acidurance (survival after 1 hr at pH 4.5 hr et al. in which both the acidogenicity and acidurance are enhanced under severe and prolonged acidic conditions. although the cultures contained a significant number of viable bacteria (Fig.5.. while non-MS and Actinomyces started to be excluded from the consortium (Fig. Correspondingly. 1997. These observations suggest that acidification impairs bacterial growth ability temporarily in a strain-dependent manner. Similar results were obtained from a batch-culture experiment (Horiuchi et al. In ECC lesions. grow again. and that more severe acidic conditions around pH 4 may exclude the nonmutans streptococci and Actinomyces. and 2. 2008).0..0.. acute infection. clearly indicative of their high acidurance..

2006). 1986.0 for 0. 0. In addition. Temporary growth impairment are a major pathogen of ECC. Frequent acidification of the acidic environment created by severe hyposalivation can be plaque by poor eating habits. 2009). The treated bacterial cells were plated (Nunn et al. In patients with permanent patients on an unrestricted diet. Bacteria (Streptococcus oralis ATCC 10557) grown at pH 7. dence of severe ECC in young children (Plutzer and Spencer. and Candida species in approximal plaque. 1976) neurological disorders. mune diseases such as Sjögren’s syndrome.. result of cancer therapy may partly explain the emergence of 2008) is in accord with the extended ecological hypothesis. 1976) have demonstrated a rapid increase in the proportion of MS parallel with the onset of Ecology of the Microflora in Patients with a Dry Mouth rampant caries. patients with a dry may be associated with the onset of caries. A 1..0 were are good predictors of ECC exposed to pH 4.. In this case.0 1000 systematic review has conControl firmed that the presence of MS. These findings remind us of ‘the mutans story’..5 1 1. and the levels treatment for head and neck cancer produces a particularly of these bacteria remained considerably lower than in irradiated aggressive form of dry mouth. 2006). 1. These Growth (OD at 660 nm) Viability (%) . The bacterial cells grown at pH 7. 2008). particularly if their oral opportunists favored by the environmental change created by hygiene practices are poor. ECC also follows the steps of the MS. suggesting that the MS A.J Dent Res 90(3) 2011 Caries-associated Bacteria in the Caries Process 299 of ECC. The data were modified from Horiuchi et al. suggesting that extended ecological plaque hypothesis. 0. increases the acidogenic/aciduric bacteria cies are known to be acidogenic and aciduric (Samaranayake and subsequently leads to dominance of the MS.0. 2002. 1.1 1 3 4 0 1 2 0 0.. while lactobacilli are mouth run a higher risk of caries... Mutans streptococci appears to be associated with a Expected 100 considerable increase in ECC Lactobacillus risk (Thenisch et al. the MS after carbohydrate consumption. radiation treatment (Brown et al. or psychogenic illness. Likewise. (2009). Klinke et al. 1990).5 2 2. (Panel B) Temporary oral health promotion programs growth impairment at pH 4. because lactobacilli are more aciduric than MS head and neck irradiation for the treatment of cancer. cessful in reducing the inciControl = growth without acid-exposure. but the most showed that deletion of dietary sucrose in the irradiated patients common reason for decreased salivation is medication. Expected = mother’s pregnancy were sucExpected growth curve calculated from surviving cell numbers after the exposure at pH 4. suggesting that the Acidification of the biofilm could also happen because of acidic environment created by hyposalivation severely destabihyposalivation. Hyposalivation can be caused by lesion initiation.0 for 1 hr in growth medium. with progreset al. Increases of Lactobacillus species were observed to lag behind those of the MS. Interestingly. in both plaque and saliva of young caries-free children. in press). since both bacterial genera are aciduric enough to colonize and Longitudinal analyses of the microflora in patients receiving proliferate in acidic caries lesions (Nakajo et al. acidification of plaque are congruent with the reciprocal adaptive microbial changes after a sugar challenge was significantly higher and more prodescribed in the extended caries ecological hypothesis. oralis ATCC 10557 formation and excessive acid streptococci production in response to a sucrose-containing diet. such as frequent intake of sugared attributed to the propagation of aciduric bacteria. longed than in control patients (Eliasson et al.. Aas et al.5. Cell viability at pH 4. 2). Therefore. but it could not be excluded sion of caries lesions.5.0. which reduces clearance of sugars and acids lized the homeostasis of the microflora.. and then incubated in growth medium at pH 7.0 for 1 hr. recent studies Time (hr) have reported that eating habits Time (hr) and socio-economic status of children and their caregivers figure 4.0 were based on repeated preventive exposed to pH 4. and 2 hrs in buffer solution. Radiation suppressed the emergence of MS and lactobacilli. Actual = guidance initiated during the Actual growth curve determined by measurement of optical density of culture medium. on blood agar and counted for colony-forming units after anaerobic incubation. Brown and co-workers (Brown et al. 2009). in which the Actual Actinomyces MS were claimed to be the 10 major pathogen in caries because of insoluble glucan non-mutans S.0 B.0. these species (Budtz-Jörgensen. hormonal disorders. the detection of lactobacilli and that acquired suppression of immune defense mechanisms as a Bifidobacterium in ECC lesions (Becker et al. patients were also colonized by higher numbers of lactobacilli.. Candida spebeverages and snacks.5 However. (Panel A) Cell viability at pH 4. autoim(Fig. These longitudinal observations hyposalivation due to radiation treatment. Effect of severe acidification on representative oral bacteria. In this context.

and as a result..300 Root-surface Caries Takahashi & Nyvad J Dent Res 90(3) 2011 Root surface caries was. the bacteria were pooled from several surfaces/lesions in the same person. (2001) observed a similar phenomenon in individuals with root-surface caries. 1974). 2009). through vaccination. a microbial shift from dynamic stability via acid-induced adaptation and selection to an aciduric stage. this may partly be because of methodological shortcomings. Preza et al. and Parascardovia. MS may comprise only a small proportion of the microflora of rootsurface caries lesions. Corby et al. pooled plaque samples cannot be expected to give a clear picture of the microbiome at a site. However. thought to be induced specifically by Actinomyces (Jordan and Hammond. reduction/substitution of the intake of sugary foods. 1993) that the ecological succession of the microflora in root-surface caries follows the same pattern as that observed for cavitated dentin caries. Nyvad. Fejerskov et al.. (1996) reported that non-MS and Actinomyces spp. the analyses have not always shown a clear-cut pattern between health and disease. the information obtained so far supports the contention (Bowden. Recent molecular studies have confirmed the abundance of Actinomyces in carious root dentin (Preza et al. It is important to appreciate. in individuals without root-surface caries. (2009b) demonstrated that the family Bifidobacteriaceae. Because of intra-oral environmental variability (Kleinberg and Jenkins. lesion activity is seldom defined. 1964. aciduric bacteria comprised only 1. and yeasts (Actinomyces were not examined). was associated with cavitated root caries lesions. 1994.4% of total microflora in clinically sound root surfaces. ‘low-pH’ Actinomyces. but acid production is also an environmental determinant that influences both the phenotypic and genotypic properties of the oral microflora through acid-induced adaptation and selection. Another shortcoming may relate to the fact that refined gene technology does not match the crude style of lesion classification commonly used. Recently. may not be an effective approach for long-term caries control. which is caused by a change from mutualistic symbiosis to parasitic symbiosis in the microbial ecosystem. Hence. Kleinberg. 2009).. as with enamel caries. 1990. Acid production is the direct causative factor in the demineralization of tooth surfaces. and root-surface caries.. investigators have advanced molecular identification methods in the attempt to resolve the microbiological foundation of caries. Aas et al. 2002). Brailsford et al.. for a long time. mutans was detected in only half of the root caries lesions (Preza et al. Rather. 2005. Collectively. Sumney and Jordan. Practical solutions to this strategy may include mechanical plaque control. because of the selective invasion of Actinomyces-like bacteria into demineralized root tissue (Nyvad and Fejerskov. There is evidence that site-specific sampling of . because of their association with mildly acidogenic environments. several elegant molecular studies have tried to elucidate the microbiological differences between clinically healthy and carious conditions (Becker et al. including Bifidobacterium. Thus. In recent years. contributes to the caries process—a view that is compatible with the mixed-bacteria ecological approach proposed by Kleinberg (2002). van Houte et al. However..e. In some studies. indicating that the acidic environment of the lesions provided a suitable habitat for the proliferation of these aciduric micro-organisms. gene therapy.and remineralization episodes may favor a net mineral loss. Even so. i. the entire consortium of acidogenic/aciduric bacteria. In this context. it is important to learn how we can stimulate a mutualistic microflora to sustain clinically healthy conditions. These authors found that aciduric bacteria able to grow at pH 4. Future microbiological studies of caries should therefore focus on a better understanding of the physiological mechanisms that serve to maintain the dynamic stability in dental biofilms. Most studies of caries microbiology do not take into account novel knowledge about the dynamic metabolic processes in caries. 1972.. While these studies have concluded that the microflora involved in caries is much more complex than hitherto anticipated. 2009). 1990). together with MS. 2008).e. This idea was probably ascribed to the sampling technique combined with the selective culturing techniques applied in these studies. lactobacilli. in response to frequent sugar intake or low salivary secretion combined with insufficient oral hygiene—the equilibrium between the de.. and/or application of pH-neutralizing techniques such as saliva stimulation. In addition to inter-individual differences (Aas et al. 2000. were dominant in dental plaque covering root-surface caries and that the isolated Actinomyces strains were heterogenous with respect to acidogenicity: Strains isolated from root-surface caries were more acidogenic than those from clinically sound root surfaces. that the enrichment of acidogenic/aciduric bacteria is a result of microbial acid formation during the caries processes—not the causative factor per se—and thus the removal of specific aciduric bacterial species such as the MS. S. environmental control of the microflora should be achieved by avoiding acidification of the dental biofilm. i. CONCLuSIONS AND fuTuRE DIRECTIONS fOR RESEARCh Our review of the literature supports the concept that dental caries is an endogenous disease. In this hypothesis. however. 2005. Scardovia. Haffajee et al. 2009). if the local environment changes—for example.7% in clinically sound root surfaces (Actinomyces-dominant). depending on the local environmental conditions. 2002.. according to the extended ecological plaque hypothesis. it is salutary to know that the caries processes can be reversed.. Mantzourani et al. of which ECC and radiation caries are classic examples. These findings point to an association between acidogenic/aciduric Actinomyces. not only the MS. it is to be expected that samples of softened carious dentin have a higher content of Gram-positive pleomorphic rods compared with samples containing superficial layers of plaque. or antimicrobial treatment. the non-mutans streptococci and Actinomyces may be interesting candidates for further analysis of their acid-base metabolic processes (Burne and Marquis. Furthermore. The caries process usually progresses rather slowly because of alternating de.. Therefore.6% of the total microflora in root-surface caries lesions (lactobacilli and Actinomyces were dominant). These processes may lead to rampant caries. whereas aciduric bacteria comprised 10.and remineralization episodes in the biofilm.8 comprised 21.

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