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ORAL

MICROBIAL
FLORA
PRESENTED BY :
DR . PRIYA SATHYAMURTHY

CONTENTS
Introduction
Taxonomy
terminologies
Classification
Ecosystem
Oral microflora
Oral econiches
Ecological relationships
Microbial complexes
Colonization of micro-organisms in the form of biofilm
Specific bacteria in periodontal diseases
Association of plaque microorganisms with
periodontal disease
Conclusion
References

MICRO ORGANISM
A microorganism (from the Greek: mikros, "small" and
organisms, "organism") is a microscopic organism,
which may be a single cell or a multi-cellular organism.
Single-celled microorganisms were the first forms of
life to develop on Earth, approximately 34 billion
years ago.
The possibility that microorganisms exist was
discussed for many centuries before their discovery in
the 17th century.

TAXONOMY
Taxonomy
Classification of living organisms into groups

Phylogenetic Classification System:


Groups reflect genetic similarity and evolutionary
relatedness

Phenetic Classification System:


Groups do not necessarily reflect genetic similarity or
evolutionary relatedness.
Instead, groups are based on convenient, observable
characteristics.

TERMINOLOGIES
Species: A collection of
microbial strains that share many
properties and differ significantly
from other groups of strains

Strain:

A culture derived from


a single parent that differs in
structure or metabolism from
other cultures of that species

Type strain: One of the first strain


among the species, studied and fully
characterised than other strains.
Biovars - prokaryotic variant strains
characterized by biochemical or
physiological differences
Morphovars - prokaryotic variant
strains characterized by morpholigical
characteristics
Serovars - prokaryotic variant
strains characterized by distinctive

Symbioses: both partners benefit


Commensalism : one partner benefits,
other is neutral

Parasitism: one partner benefits while the


other is harmed

Mutualism: different organisms living


together

Mechanism of
pathogenesis
Transmission
Adherence
Invasion
Colonization
Damage
Exit
Survival

Prokaryotes
Prokaryotes are organisms that
lack a cell nucleus and the other
membrane bound organelles.
They are almost always
unicellular.
Consisting of two domains,
bacteria and archaea.

CELL STRUCTURE OF
PROKARYOTE
1.- flagella
2.- pili (fimbriae)
3.- capsules
4.- slime layer

BACTERIA
They lack a nucleus and other membranebound organelles, and can function and
reproduce as individual cells, but often
aggregate in multicellular colonies. Their
genome is usually a single loop of DNA.

ARCHAEA

Archaea differ from bacteria in both their


genetics and biochemistry.
For example, while bacterial cell membranes are
made from phosphoglycerides with ester bonds,
archaean membranes are made of ether lipids.

EUKARYOTES
Most living things that are visible to the naked eye in
their adult form are eukaryotes, including humans.
Unlike bacteria and archaea, eukaryotes contain
organelles such as the cell nucleus, the Golgi
apparatus and mitochondria in their cells.

SHAPES

GRAM (+) OR (-) ?


PEPTIDOGLYCAN LAYER :

EXCEPTIONS TO GRAM STAINING


1.- MYCOBACTERIUM : ACID FAST
2.- SPIROCHETES

: DARK FIELD

3.- MYCOPLASMA : NO CELL WALL

ATMOSPHERE
AEROBIC : That can survive and grow
in an oxygenated environment.

ANAEROBIC : That does not


requireoxygenfor growth.

Amicroaerophileis amicroorganismthat
requiresoxygento survive, but requires
environments containing lower levels of oxygen
than are present in theatmosphere.

Capnophiles, require an elevated concentration


ofcarbon dioxide to survive. Eg:Campylobacter
spp.

ANAEROBIC
Obligate anaerobes, which are harmed by the
presence of oxygen. Bacteroides, Clostridium,
Fusobacterium,, Porphyromonas, Prevotella,
Aerotolerant organisms, which cannot use
oxygen for growth, but tolerate its presence
Facultative anaerobes, which can grow
without oxygen but use oxygen if it is present.
Staphylococcus spp., Streptococcus spp.,
Escherichia coli, Listeria spp.

TEMPERATURE
PSYCHROPHILIC: Temperatures below

15 degrees.
MESOPHILIC: temperatures between 20

-45 degrees.
THERMOPHILIC : temperatures above

60 degrees

BACTERIAL METABOLISM
pH :
Neutrophil
Acidophil

68

Alkalophil

10.5

AEROBIC GRAM (+) COCCI


STAPHYLOCOCCUS
STREPTOCOCCUS

AEROBIC GRAM (-) COCCI


NEISSERIA
SALMONELLA
ESCHERICHIA
VIBRIO
HELICOBACTER
BRUCELLA

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ECOLOGICAL
NICHE
&
Anicheis a term describing the way of life of
a species.
ECOSYSTEM
Each species is thought to have a separate,
unique niche.

The ecological niche describes how an


organism or population responds to the
distribution of resources and competitors and
how it in turn alters those same factors for its
benefit.
The
ecosystem is composed of microbial
communities living on specific sites surrounded
by a different physical and chemical elements.

Definitions of Hutchinson: The set of biotic and


abiotic conditions in which a species is able to
persist and maintain stable population sizes."

Ways of obtaining and using


nutrients
Nutrition
Autotrophic
nutrition

Holozoic
nutrition

Heterotrophic
nutrition

Saprophytic
nutrition

Parasitic
nutrition

ORAL MICROFLORA

Oral microflora refers to the community of


microorganisms coexisting in the oral cavity as its
primary habitat;
These strains of bacteria colonize the various
different surfaces present in the oral cavity, and
communicate between each other through
complex cell signaling processes;
Over time as the individual is further exposed to
external sources of bacteria, the biodiversity of the
oral cavity increases, to a point where stability is
reached.
This is termed the climax community.

THE SOURCE OF
MICROORGANISMS
At birth the oral cavity is sterile but rapidly
becomes colonized from the environment,
particularly from the mother in the first feeding.

Streptococcus salivariusis dominant and may


make up 98% of the total oral flora until the
appearance of the teeth (6 - 9 months in humans).
Majority of children obtain their resident microflora
from their mothers, as they often possess identical
strains of bacteria;
This is known as vertical transmission;
Horizontal transmission also takes place as
children interact with their peers, and later in life
between spouses and partners.

BACTERIA DURING THE


LIFE CYCLE
Oral colonization begins in
the birth canal:
Populations on the tongue
and mucosa;
Established during infancy
- include anaerobes;
Tooth eruption provides nonshedding surfaces:
The window of infectivity
concept;
Colonization from source
sites and caregiver saliva;

Hormonal shifts - puberty and pregnancy:


Can alter proportions of Gm- anerobes;

Complete loss of teeth shifts flora towards


infant state:
Dentures restore supragingival non-shedding
sites;
Implants restore supra- and subgingival sites.

ORAL FLORA CHANGES WITH


AGE
Time during a
lifetime

MAJOR COMPONENTS & CHANGES IN ORAL


FLORA

Newborn

Oral cavity sterile. Soon colonised by


facultative and
aerobic organisms; esp S. salivarius

6 months

Flora becomes more complex & includes


anaerobic
orgs eg. Veillonella sp. & Fusobacteria

Tooth eruption

Increase in complexity. S sanguis, S mutans


and A
viscosus appear. New habitats include hard
surfaces
and gingival crevice.

Child to adult

Various anaerobes frequently found inc.


Members
of the Bacteroidaceae. Spirochaetes isolated
more
frequently

FORMATION OF THE
ECOSYSTEM

The development of microbial community


comprises an alternation of populations;

The process starts with the colonization of the


environment of the first microbial population;
It fills the new space, modify it and makes it
convenient for resettlement of new microbial
population.
Growing microbial community was enriched
with different species living in complex;
The process of alternation of populations and
enrichment of the community stops only when
niches for colonization of new microbial species
are unavailable.

DIVERSE ECOLOGICAL NICHES


IN THE ORAL CAVITY
The heterogeneity of tissue types in the
oral cavity, such as teeth, tongue and
mucosa, means that a variety of sites are
available for colonization by oral
microorganisms;
Each site has unique characteristics and
allows those microorganisms best suited to
the environment to inhabit the site.

Dynamic Equilibrium:
(1) Swallowing, Mastication, Or Blowing The Nose
(2) Tongue And Oral Hygiene Implements
(3) The Wash-out Effect Of The Salivary, Nasal, And
Crevicular Fluid Outflow
(4) Active Motion Of The Cilia (Nasal And Sinus Walls).
Most organisms can only survive in the oropharynx
when they adhere to either the soft tissues or the
hard surfaces (teeth, dentures, and implants).
40

ORAL CAVITY DIVIDED INTO 5 MAJOR


NICHES

41

ORAL ECOLOGICAL ZONES


Mostly the same species are present, but
proportions may differ;
High biomass sites:
Non-shedding surfaces:
Supragingival tooth surfaces;
Subgingival tooth surfaces;

Shedding surface:
The tongue;

Low biomass (reservoir) sites;


Shedding oral mucosal surfaces:
Buccal, palate, external gingiva, floor of mouth;

Saliva as a transitional zone.

ORAL ECONICHES
Hard structures teeth, providing
various locations for colonization:
Subgingival;
Supragingival;

Soft structures mucosa:


Cheeks, lips, tongue, gingiva, palate;
Keratinized and nonkeratinized mucosa;
Epithelium of the gingival sulcus.

MUCOSAL SURFACES:
These include the palate, cheek and tongue, which
have cells which are constantly replaced due to
the normal wear-and-tear of the mouth;
The different mucosal surfaces also have different
properties which contribute to the presence of
different types of bacteria:
The presence of the numerous crypts on tongue
allows for bacteria to be protected from the
normal shedding and removal by saliva flow,
Hence species not found elsewhere, such as
obligate anaerobes, can be found on the dorsum
of the tongue.

MUCOSAL RESERVOIR
SITES
Some oral species can invade epithelial
cells:
This requires communication between
bacteria and cells;
Bacteria subvert the cell to take them in:
Take control of the cytoskeleton;
Can live and grow inside;

Can direct the cell to export them to


other cells;

Multi-species intracellular flora


resembles mixed biofilm.

MUCOSA OF THE GINGIVA, PALATE,


CHEEK, FLOOR OF THE MOUTH

Surface of the tongue


Streptococcus:

Streptococcus salivarius, S. mitis;

Veillonella spp.;
S. oralis, S. sanguis;
Peptostreptococcus spp.
Neisseria;

Haemophilus;

Gram + rods - Actinomyces spp.;

Veillonella.

Gram - rods - Bacteroides spp.;

Obligate anaerobes black - rods an


spirochetes associated with
periodontal diseases.

DENTAL ECONICHES
SUPRAGINGIVAL PLAQUE:
Gram positive MO;
Facultative anaerobes:
Streptococcus;
Actinomyces;

Gram negative:
Veillonella, Haemophilus,
Bacteroides

SUBGINGIVAL PLAQUE
From

healthy gingival sulcus


isolate:
Gram

negative rods:

Porphyromonas

gingivalis;

Porphyromonas

endodontalis;

Prevotella

melaninogenica;

Prevotella

intermedia;

Prevotella

loesheii;

Prevotella

denticola.

SUBGINGIVAL TOOTH
SURFACES

They are the narrow crevice between gingival


epithelium and cementum
They have low oxygen tension which is
favorable for Gm- anaerobes;
Major site for interaction between bacteria
and host tissues;
Species mix varies
between each side
and the center which
form distinct
microenvironments.

ORAL FLUIDS
Oral surfaces washes of two liquids:
Saliva;
Gingival fluid;

They are the basis for maintaining oral


ecosystem:
Provide water;
Nutrients;
Adhesion;
Antimicrobial factors.

MICROORGANISMS IN SALIVA
Microbial composition of saliva is the most
similar to the tongue.
By acting as a buffer, saliva maintains the pH
of the mouth, ensuring the optimal growth of
the resident colonies;
Most of the microbes present in the mouth
utilize the glycoproteins and proteins in the
saliva as their main source of nutrition;
Proteins and glycoproteins of saliva are
responsible for the formation of the pellicle.

SALIVARY FLOW
It is responsible for the removal of nonendogenous bacteria which is unable to adhere to
specific sites in the mouth;
Areas which receive markedly less saliva flow,
such as deep gingival crevices, proximal spaces
and occlusal fissures, tend to have significantly
higher levels of bacterial buildup;
Saliva is carrying bacteria - the main source of
microbial transmission between individuals;
Saliva also circulates bacteria within the oral
cavity, resulting in re-colonization of oral surfaces
where the microflora might be removed via
mechanical forces such as cleaning.

GINGIVAL CREVICULAR
FLUID:
The flow of this fluid removes foreign microbes
which do not adhere to these surfaces;
For the resident population, the flow of
crevicular fluid provides these organisms with a
source of nutrition.

NORMAL - RESIDENT
FLORA
In a healthy body, the internal tissues
- blood, brain, muscle, etc., are
normally free of microorganisms;
However, the surface tissues - skin
and mucous membranes, are
constantly in contact with
environmental organisms and become
readily colonized by various microbial
species;
The mixture of organisms regularly found at any
anatomical site is referred to as thenormal
flora or resident flora, some researchers
prefer the term "indigenous microbiota".

RESIDENT MICROFLORA
Typical microflora of a econiche;
Microorganisms are separated and grouped according to
the different conditions of life;
Resident microflora has an important function in host:
Digestive and nutritional;
Competition with pathogenic microflora.

PATHOGENICITY OF
Microflora usually is non-pathogenic and form an
MICROFLORA
integral part of the host;

The presence of friendly resident microorganisms on oral


surfaces contributes to the bodys defense against
foreign pathogens, which are generally transient and
can give rise to harmful infections.

This is known as colonization resistance;

FUNCTION OF MICROFLORA
Colonization resistance is firstly achieved through the
saturation of oral surfaces with preexisting resident
bacteria, which reduces the available sites left for the
attachment of exogenous organisms;
Essential nutrients derived from the saliva and various
proteins in the oral cavity are also more effectively utilized
by the resident microflora, which inhibits infections via
competition for resources;

THE NORMAL BACTERIAL FLORA OF


THE ORAL CAVITY
Benefit from the host who provides nutrients and habitat;

Occupy available colonization sites which makes it more difficult


for other microorganisms to become established;

Contribute to host nutrition through the synthesis of vitamins, and


they contribute to immunity by inducing low levels of circulating
and secretory antibodies that may cross react with pathogens;

Exert microbial antagonism against exogenous species by


production of inhibitory substances such as fatty acids, peroxides
and bacteriocins.

TRANSIENT MICROBIOTA
Transient microbes are just passing through;
Although they may attempt to colonize the same areas of
the body as do resident microbiota, transients are unable
to remain in the body for extended periods of time due to:
Competition from resident microbes;
Elimination by the bodys immune system;
Physical or chemical changes within the body that discourage
the growth of transient microbes.

OPPORTUNISTIC MICROBES

Under normal conditions, resident and transient microbes


cause the host no harm;

However, if the opportunity arises, some of these


microbes are able to cause disease and become
opportunistic pathogens.

THIS CAN HAPPEN DUE TO A NUMBER OF


DIFFERENT CONDITIONS:
When the immune system is compromised or suppressed, normal
flora can overpopulate or move into areas of the body where they
do not normally occur;
When the balance of normal microbes is disrupted, for example
when a person takes broad spectrumantibiotics, microbes that
are normally crowded out by resident microbes have an
opportunity to take over;
Disease can result when normal flora are traumatically introduced
to an area of the body that they do not normally occur in.

ENDOGENOUS MICROFLORA
That is microflora already present in the body, but has
previously been inapparent or dormant.

EXOGENOUS MICROFLORA

Exogenous bacteriaare microorganisms introduced to


closedbiological systemsfrom the external world;

They exist in aquatic and terrestrial environments, as


well as the atmosphere;

Exogenous bacteria can be either be benign or


pathogenic.

ECOLOGICAL RELATIONSHIPS
Independence
Life free from influences, management or control of
other organisms.

Dependence
MICROBIAL RELATIONSHIPS

There are a complex of relationships


between different microbial species:

Neutral;

Antagonistic microbial interactions;

Synergistic.

NEUTRAL

Relationship between two species living together without


affecting each other - neither favorable nor unfavorable.

SYNERGY

Relationships between the two microbial species living together,


wherein both are mutually favored, leading to enhancement of the
effects of each of these.

Example of synergy

Various microorganisms may cooperate to use substances


which they are not able to metabolise themselves;

P. gingivalis and F. Nucleatum both can hydrolyze


casein.

ANTAGONISM
Relationship of two microbial species living together,
yielding inhibition of their function, and less effect on the
independent operation of each one of them.

Mechanisms of microbial
Competition for adhesion receptors or for nutrients;
antagonism

Production of inhibitory substances:

Organic fatty acids;

Hydrogen peroxide:

Dairy complex;

Antibiotics;

Enzymes;

Bacteriocins.

AN EXAMPLE OF MICROBIAL
ANTAGONISM
S. mutans and Lactobacillus produce lactic acid
thereby producing an acidic environment;
It inhibits the growth of S.sanguis and S. oralis,
and gram negative microorganisms;
Separation by bacteriocins inhibit gram
positive microorganisms.

INFLUENCE OF EXTERNAL FACTORS

Diets : Food high in carbohydrates increases the


development of Str. mutans and Lactobacillus;
A diet high in protein inhibits the development of
Lactobacillus.

Oral hygiene and antimicrobial agents :


Good oral hygiene:
Facultative aerobes;
Acidogenious microorganisms;

Neglected oral hygiene:


Anaerobes;
Proteolytic microorganisms.

Drugs and diseases.

ANTIMICROBIAL
AGENTS
Fluorides have depressing
effect on microbial
attachment.
Reducing sugar transport;
Reduce their glycolytic activity;
Suppress the acid tolerance of gram +
microorganisms,

DRUGS AND DISEASES

Patients with reduced salivation have reduced capacity


to remove sugars, reduced buffering capacity.

Antibiotics suppress the resident microflora, leading to


over-development of antibiotic resistant species Candida and allow colonization of exogenous pathogens
such as Enterobacteriaceae.

BENEFICIAL EFFECT OF THE


MICROFLORA ON THE BODY
Prevent exogenous and endogenous infections;
Stimulate an immune response;
Help in renewal and healing of the epithelium;
Deliver certain biological factors to the host.

ADVERSE EFFECTS

Source of endogenous infection;

Change the local environment to facilitate


exogenous microbial overdevelopment.

Create hypersensitivity in organism to


microbial agents.

HUMAN ORAL FLORA


GRAM-POSITIVE FACULTATIVE
COCCI
Staphylococcus epidermidis
Staph. aureus
Streptococcus mutans
Strep. sanguis
Strep. Mitis
Strep. Salivarius
Strep. Faecalis
Beta-hemolytic streptococci

GRAM-NEGATIVE FACULTATIVE
RODS
Enterobacteriaceae
Hemophilus influenzae
Eikenella corrodens
Actinobacillus
Actinomycetemcomitans

GRAM-POSITIVE ANAEROBIC
COCCI
Peptostreptococcus sp

GRAM-NEGATIVE ANAEROBIC
COCCI
Diphtheroids
Corynebacterium

GRAM-POSITIVE ANAEROBIC
RODS
Actinomyces israelii
A. odonotolyticus
A. Viscosus
Lactobacillus

GRAM-NEGATIVE AEROBIC OR
FACULTATIVE COCCI
Eubacterium
Neisseria sicca
N. Flavescens

SPIROCHETES

YEASTS

Treponema denticola
T. Microdentium

Candida albicans
Geotrichum sp.

Protozoa

Mycoplasma

Entamoeba gingivalis
Tirchomonas tenax

Mycoplasma orale
M. pneumoniae

IMPORTANT ORAL BACTERIA


1. Gram Positive organisms:

Rods (bacilli), cocci or irregular shape (pleomorphic);


Oxygen tolerance varies from aerobes to strict
anaerobes;
Most are fermentative;
Cell wall has thick peptidoglycan layer (penicillin has
effect by interfering production of this layer).

THREE IMPORTANT GENERA:


Actinomyces is facultative anaerobe;
Lactobacillus, produce lactic acid, facultative anaerobe,
role in dentine caries rather than enamel caries;
Streptococcus is facultative anaerobic cocci which
produces lactic acid Some are implicated in caries.

IMPORTANCE OF STREPTOCOCCI IN THE


ORAL
AND THEIR PROPERTIES
Importan
t
Oral
Species

Growth
on
hard
surfaces

Production
of Insol.
Extracellular
Polysaccharide

Production
of Acid

Cariogeni Endoc
carditis
isolates

S mutans

+++

S sanguis

++

++

S mitis

+
_

+
_

+
_

+++

S milleri

S
salivarius

DISTRIBUTION OF STREPTOCOCCI
IN THE ORAL
CAVITY
Species

Cheek

Tongue

Saliva

Tooth

S.mutans

+/-

++

S. mitis

+++

+++

+++

+++

S. salivarius

++

++

2. GRAM NEGATIVE ORGANISMS


Many Gram-negative bacteria are found in the
mouth, especially in established/subgingival
plaque;
Mainly consist of Cocci, rods, filamantous rods,
spindle shaped or spiral shaped;
Range of oxygen tolerance but most important
strict or facultative anaerobes;
Some fermentative, produce acids which other
organisms use acids as an energy source, others
produce enzymes which break down tissue;

MOST IMPORTANT GRAM NEGATIVE


BACTERIA:

Porphyromonas: P. gingivalis

Prevotella: P. intermedia
Fusobacterium: F. nucleatum periodontal
pathogen;
Actinobacillus/Aggregatibacter:
A.actinomycetemcomitans associated with
aggressive periodontitis;
Treponema: group important in acute
periodontal conditions i.e ANUG;
Neisseria;
Veillonella.

FLORA OF NORMAL, HEALTHY DENTATE


MOUTH
% (approx)

85%

Remainder

Bacteria

Streptococci
Veillonella
Gram positive Diptheroids
Gram negative anaerobic rods

5-7%

Neissaeria

2%

Lactobacilli

1%

Staphylococci & Micrococci


Other bacteria, fungi,
protozoa & viruses

FUNGI IN THE ORAL CAVITY


Most commonly found :- candida species
(C.albicans, C. tropicalis, C. stellatoidea, C.
parapsilosis, C. guilliermondi)
Other rhodotorula & torulopsis ( denture
wearer)
Conditions thrush ,erythematous
candidiasis,hyperplastic candiasis,angular
chelitis
Medium used sabouraands agar(peptoneglucose)
Indentification psuedohyphae, septate hyphae

77

PARASITES IN THE ORAL CAITY


ENTAMOEBA GINGIVALIS
TRICHOMONAS TENAX

E. gingivalis
found in soft calculus,periodontal pockets and infection of tonsils
Can become opportunistic
pathogen

T.tenax
only parasitic flagellate in
oral cavity
--number increases in periodontitis
78

FACTORS AFFECTING GROWTH OF


MICROORGANISMS IN THE ORAL
CAVITY
1. Temperature;
2. REDOX Potential / Anaerobiosis;
3. pH;
4. Nutrients (endogenous & exogenous (diet);
5. Host Defences (Innate & Acquired immunity);
6. Host genetics (changes in immune response
etc);
7. Antimicrobial agents & inhibitors.

TEMPERATURE
Relatively constant - 34-36 ;
The temperature is variable on the teeth and mucosa;
When microorganisms colonize they are exposed to
extreme temperatures;

PH, OR HYDROGEN ION


CONCENTRATION
In the mouth pH varies between 6.7 and 7.3;

It is maintained by saliva through salivary flow and


buffer systems;

In an acid medium in the eco niches following are


developed:

Lactobacillus;

Str. mutans;

In the gingival sulcus pH is alkaline -7.5 - 8.5;


In the gingival fluid pH is 7.5 7.9 .

REDOX
POTENTIAL
AND
Under the action of the enzymes some of the
ANAEROBIOSIS
components are subjected to oxidation, and
others to reduction;
These processes depend on the oxygen and
their redox potential;
In a predominance, reduction processes have a
negative redox potential and develop
anaerobic microorganisms;
Positive redox potential are seen in buccal and
palatal mucosa and the posterior part of the
tongue;
Negative redox potential are seen in
approximal surfaces, fissures and gingival
sulcus.

NUTRIENTS
Desquamated epithelial cells;
Gingival fluid;
Saliva;
Residues from host`s food;
Products of metabolism of other
microbial species.

HOST FACTORS

Host defense mechanisms;

Hormonal changes;

Stress;

Genetic factors.

RELATIONSHIPS WITH THE HOST


Host defenses in the mouth:
Epithelial cells:
Barrier function;
Innate immunity - sensors (Toll-like receptors);
Inflammatory mediators, antimicrobial peptides;

Salivary antimicrobial factors


Mucosal antibodies (secretory IgA);
Cell-mediated immunity (T-cells);

In most cases, host defenses tolerate oral


bacteria
The predominant relationships are commensal.

HOST DEFENSE MECHANISMS


Remove the microorganisms through stimulation of
salivary flow;
Specific protection:
Salivary Ig A;

Nonspecific protection:
Mucin;
Antimicrobial factors:
Lysozyme;
Lactoferrin;
Salivary peroxidase;
Histatine-rich peptides;
Cistatin;
Leukocytes;
Complement.

REMOVAL OF THE
The majority of microorganisms in the mouth is removed
MICROORGANISMS
by washing action of saliva;

Salivary flow is stimulated by muscle activity of lips and


tongue.
The soft tissue surfaces employ a variety of mechanisms
to prevent adhesion of pathogenic organisms.

One of the most important mechanisms is shedding.

The high turnover rate of the intraoral epithelial cells,


especially of the gingiva, prevents the permanent
accumulation of large masses of microorganisms on these
surfaces. In essence, this is a natural cleansing
mechanism.

However, bacteria can adhere to host cells and form a


commensal relationship, beneficial for both parties.

SPECIFIC PROTECTION - SECRETORY


IGA SYSTEM
SIgA-antibodies reduce microbial adhesion to
enamel epithelium and through:
Neutralizing enzymes
Neutralize toxins
Synergy with other antibacterial agents such as
lysozyme, lactoferrin, peroxidase and mucin;

Protects the mucosa of penetration of antigens;


Helps complement activation.

MUCIN
Provides a protective coating of enamel and mucosa;
Catches microorganisms and antigens like in a trap;
Limits microorganisms penetration into tissues;
Eliminates microorganisms with continuous updating
of mucin layer combined with washing action of
saliva flow;
As part of pelicle protects teeth from
demineralization.

COLONIZATION OF
MICRO-ORGANISMS
IN THE ORAL CAVITY

ADHESION
Adhesins can be of the microbial surface and receptors on
oral surfaces
The association of bacteria within mixed biofilms is not
random, rather there are specific associations among
bacterial species.
Socransky et al (1998)

MICROBIAL ADHESINS
Constructed of:
Polysaccharides;
Lipoteichoic acid;
Glycosyltransferase;
Carbohydrate-binding proteins;

They are located in the cell wall in the form of:


Fimbriae; Fibrils; Capsules.

RECEPTORS ON THE ORAL


STRUCTURES
SALIVARY COMPONENTS

BACTERIAL COMPONENTS

Mucin;

Glycosyltransferase;

Glycoproteins;

Glucans.

Amylase;
Lysozyme;
IgA, IgG;
Proline-rich proteins.

BACTERIAL ATTACHMENT TO A
SURFACE CAN BE DIVIDED INTO
SEVERAL DISTINCT PHASES
Primary and reversible adhesion;
Secondary and irreversible adhesion;
Biofilm formation.

CO-AGGREGATION
Coaggregation interactions are believed to
contribute to the development of biofilms by two
routes:

The first route is by single cells in suspension specifically


recognizing and adhering to genetically distinct cells in the
developing biofilm;

The second route is by the prior coaggregation in suspension


of secondary colonizers followed by the subsequent adhesion
of this coaggregate to the developing biofilm;

In both cases, bacterial cells in suspension


(planktonic cells) specifically adhere to cells in the
biofilm in a process known as coadhesion.

ECOLOGICAL SIGNIFICANCE OF BACTERIAL COAGGREGATION

Specific coaggregation processes are likely to have


an important ecological role as an integral process in
the development and maintenance of mixed-species
biofilm communities;
Strengthens bacterial attachment;
Increases the stability of the plaque matrix.
ADHESION IS DEPENDENT ON:

A contact: Start of interaction;

A dose: There is a certain amount of microorganisms;

Frequency of exposure: Partial colonization;

Adsorption:

By electrostatic forces to the surface of


pellicle;

With specific receptors on the cell surfaces;

Bacterial cells within biofilms can produce enzymes


such as beta-lactamase against antibiotics,
catalases, and superoxide dismutases against
oxidizing ions released by phagocytes.
These enzymes are released into the matrix
producing an almost impregnable line of defense.
Bacterial cells in biofilms can also produce elastases
and cellulases which become concentrated in the
local matrix and produce tissue damage.
94

DENTAL BIOFILM

Biofilm is a highly organized structure and consists of


microcolonies of bacterial cells randomly distributed in a
shaped matrix or glycocalyx.
Biofilms can facilitate processing, uptake of nutrients, cross
feeding, removal of harmful metabolites and development of
appropriate physicochemical environment.
Lower plaque layer are dense in which microbes are bound
together in polysaccharide matrix with other organic and
imorganic materials.
On top of lower layer, loose layer can be seen which can extend
into surrounding medium (for teeth and saliva)
The fluid layer bordering the biofilm has a stationary sublayer
and a fluid layer in motion
Nutrient components penetrate this fluid medium by molecular
diffusion
Biofilms act as primitive circulatory system.
Microcolonies occur in different shapes according to shear
forces.

95

BIOFILM

The classic biofilm that involves components of the normal


flora of the oral cavity is the formation of dental plaque on
the teeth; it has open fluid filled channels running across the
plaque mass

Plaque is a naturally-constructed biofilm, in which the


consortia of bacteria may reach a thickness of 300-500 cells
on the surfaces of the teeth;

These accumulations subject the teeth and gingival tissues


to high concentrations of bacterial metabolites, which result
in dental disease.

High rate of reproduction and physiological adaptation to


environmental resources help biofilms to survive and
sustain.
Changes in shear forces, mass transfer, nutrient
concentrations and quorum sensing influence biofilm
properties

BIOFILM FORMATION

EXOPOLYSACCHARIDES THE
BACKBONE
OF BIOFILMS
The bulk
of the biofilm consists of the matrix or
glycocalyx and is composed predominantly of water
and aqueous solutes.
The dry material is a mixture of
Exopolysaccharides, proteins, salts, and cell
material.
Exopolysaccharides (EPS), produced by the bacteria
in the biofilm, are the major components of the
biofilm making up 5095% of the dry weight.
They play a major role in maintaining the integrity
of the biofilm as well as preventing desiccation and
attack by harmful agents.
In addition, they may also bind essential nutrients
such as cations to create a local nutritionally rich

98

They can be neutral or charged polyanionic


macromolecules and different concentrations can
alter the conformation of the gel network.
They can exist in ordered and disordered forms.
The density of fibrillar masses and the flexibility
and configuration changes could affect
accessibility to nutrients and solutes.
The EPS matrix could also act as a buffer and
assist in the retention of extracellular enzymes
(and their substrates) enhancing substrate
utilization by bacterial cells.

Quorum sensing tells


bacteria when to grow,
and when its time to
go;
Bacteria at the outer
surface of mature
biofilms are signaled
to detach and become
planktonic;
Different genes are
active in planktonic
and biofilm states.

1 colonizers (Gram+)
Streptococci bind pellicle
proteins from saliva DENT 5302;
2 colonizers (Gram-)
Bridge species - F.
nucleatum
Bind other bacteria

3 colonizers (Gram-)
Porphyromonas gingivalis

ECOLOGICAL
SUCCESSION

INTER-SPECIES COMMUNICATION
Streptococci ferment CHO;
Excrete lactic acid;
Veillonella use lactate made by
Strep for nutrition;
They are biofilm buddies.
Strep can make amylase;
Starch-digesting enzyme;
Enhances lactate excretion;

POTENTIAL NUTRITIONAL INTERACTIONS


BETWEEN PLAQUE BACTERIA

INTERSPECIES COLLABORATION O
2
Streptococcus
cristatus:
Facultative species:
Fusobacterium nucleatum:
Robust anaerobe;
Binding to strep improves
survival when O2 is present;
Porphyromonas gingivalis:
Sensitive anaerobe;
Coaggregation essential to
survival when O2 is present.

COLLABORATIVE INVASION
F. nucleatum invades
epithelial cells;
S. cristatus does not
invade cells;
After coaggregation, S.
cristatus is carried inside
by F. nucleatum.
Streptococcus cristatus thus coaggregates with F.
nucleatum

Fusobacterium nucleatum is considered a bridge


species because it is a promiscuous coaggregator.

Primary
Colonizer
s

1. Streptococcus gordonii
2. Streptococcus intermedius
3. Streptococcus mitis
4. Streptococcus oralis
5. Streptococcus sanguinis
6. Actinomyces gerencseria
7. Actinomyces israelii
8. Actinomyces naeslundii
9. Actinomyces oris
10.Aggregatibacter actinomycetemcomitans
serotype a
11.Capnocytophaga gingivalis
12.Capnocytophaga ochracea
13.Capnocytophaga sputigena
14.Eik enella corrodens
15.Actinomyces odontolyticus
16.Veillonella parvula

106

Secondar
y
Colonizer
s

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Campylobacter gracilis
Campylobacter rectus
Campylobacter showae
Eubacterium nodatum
Aggregatibacter actinomycetemcomitans
serotype b
Fusobacterium nucleatum ssp nucleatum
Fusobacterium nucleatum ssp vincentii
Fusobacterium nucleatum ssp polymorphum
Fusobacterium periodonticum
Parvimonas micra
Prevotella intermedia
Prevotella loescheii
Prevotella nigrescens
Streptococcus constellatus
Tannerella forsythia
Porphyromonas gingivalis
Treponema denticola
107

STRUCTURE AND COMPOSISTION OF


DENTAL PLAQUE1
Dental plaque is composed primarily of microorganisms. One
gram of plaque (wet weight) contains approximately 10 11
bacteria.
In a periodontal pocket,
Healthy crevice -

103 bacteria.

Deep pocket - 108 bacteria.


Nonbacterial microorganisms that are found in plaque
include Mycoplasma species, yeasts, protozoa, and viruses.

108

Subgingival
Tissue
associated

St. oralis, St. intermedius


Peptostreptcoccus micros
P. gingivalis, P. intermedia
T. Forsythis, F. Nucleatum

109

DIFFERENCE BETWEEN MATURE SUPRA


& SUB-GINGIVAL PLAQUE
Characteristic

Supra gingival

Sub gingival

Grams stain

Gram + or -ve

Mainly Gram ve

Morphotypes

Cocci, branching
rods, filaments &
spirochaetes

Mainly rods &


spirochaetes

Energy Metabolism

Facultative, some
anaerobic

Mainly anaerobic

Energy source

Mainly ferment
carbohydrate

Many proteolytic
forms

Motility

Few

Many

Pathology

Caries & gingivitis

Gingivitis &
periodontitis

Attached plaque: tooth associated and


predominantly composed of gram +ve rods
and cocci
Cause subgingival calculus and root caries
Unattached plaque: extends to frontier of
apical plaque and have gram ve organisms.
Form the bioactive area and cause large
amount of inflammatory GCF
Epithelium associated: loosely attached to
gingival epithelium and contain gram ve and
motile rods. Most important group in
periodontal pathgenesis

112

MICROBIOLOGY OF
PERIODONTAL DISEASES
ARE THERE TRUE ORAL PATHOGENS?
Classic concept of a pathogen
Not normally present
Produces virulence factors
Damage host directly (e.g. toxins)
Induce host to damage itself (immune responses)

Presumed oral pathogens dont quite fit that model


Normally present throughout life
Damage requires presence in large numbers

Ecological concept of oral microbial diseases


Ecological shifts lead to changes in proportions
Balance shifts in favor of pathogens/disease

SIMILARITY BETWEEN
PERIODONTAL DISEASES AND
OTHER INFECTIOUS
DISEASES

Individuals may be colonized continuously by


periodontal pathogens at or below the gingival
margin and yet not show evidence of ongoing or
previous periodontal destruction.

In spite of the presence of periodontal pathogens,


periodontal tissue damage does not take place.
This phenomenon is consistent with other
infectious diseases in which it may be observed
that a pathogen is necessary but not sufficient for
a disease to occur.

114

UNIQUE FEATURES OF PERIODONTAL


The major reason forINFECTION
this uniqueness is the unusual
anatomic feature that a mineralized structure, the tooth
passes through the integument, so that part of it is
exposed to the external environment while part is
within the connective tissues.

The tooth provides a surface for the colonization of a diverse


array of bacterial species.
Bacteria may attach to the tooth itself, to the epithelial
surfaces of the gingiva or periodontal pocket, to
underlying connective tissues, if exposed, and to other
bacteria which are attached to these surfaces.
Thus, a situation is set up in which microorganisms colonize a
relatively stable surface, the tooth and are continually held in
immediate proximity to the soft tissues of the periodontium.

115

The organisms that cause periodontal diseases


reside in biofilms that exist on tooth or epithelial
surfaces.
The biofilm provides a protective environment for
the colonizing organisms and fosters metabolic
properties that would not be possible if the
species existed in a free-living (planktonic) state.

HISTORICAL PERSPECTIVE
Investigators in the period from 18801930
suggested four distinct groups of microorganisms
as possible etiologic agents; amoeba,
spirochetes, fusiforms, and streptococci.

116

AMOEBA
They found higher proportions of amoeba in
lesions of destructive periodontal diseases than in
samples taken from sites in healthy mouths or
mouths with gingivitis.
The role of amoeba in periodontal disease was
questioned by some authors because amoeba
were found in sites with minimal or no disease
and could not be detected in many sites with
destructive disease and because of the failure of
emitin to ameliorate the symptoms of the disease.

SPIROCHETES

Investigators reported higher proportions of


spirochetes and other motile forms in lesions of
destructive disease when compared with control
sites in the same or other individuals.

118

FUSIFORMS
The third group of organisms that were frequently suggested to be
etiologic agents of destructive periodontal diseases, including
Vincents infection, were the spindle-shaped fusiforms.
These organisms were originally recognized on the basis of their
frequent appearance in microscopic examination of subgingival
plaque samples.
The organisms were first related to periodontal disease by Plaut
(1894).
Vincent (1899) distinguished certain pseudomembranous lesions of
the oral cavity and throat from diphtheria and recognized the
important role of fusiforms and spirochetes in this disease.

STREPTOCOCCI
These microorganisms were proposed on the basis of cultural
examination of samples of plaque from subgingival sites of
periodontal disease.
The selection of the streptococci may have been predicated upon
the fact these were the only species that could be consistently
isolated from periodontitis lesions using the cultural techniques of
that era.

119

ACTINOBACILLUS ACTINOMYCETEMCOMITANS
Aclinobaciltus" refers to the internal star-shaped morphology of
its bacterial colonies on solid media (Colebrook 1920) and to the short
rod or bacillary shape of individual cells (Lieske 1921, Slots 1982).
This is a small, non-motile, Gram-negative, saccharolytic,
capnophilic, round-ended rod.
This species was first recognized as a possible periodontal
pathogen in lesions of localized juvenile periodontitis. (Newman et al
1976, Slots 1980, Chung et al 1989) .
Subjects harboring A. actinomycetemcomitans with the 530 bp
deletion were 22.5 times more likely to convert to LJP (Bueno et al
1998).

120

It was originally named Bacterium actinomyeetum comilans (Klinger


1912) which was changed to Bacterium comitans (Lieske 1921) and
finally to Actinobacilius actinomycetemcomitans (Topley & Wilson
1929),
Recently, Actinobacillus actinomycetemcomitans, Haemophilus
aphrophilus and Haemophilus segnis to a new genus Aggregatibacter
gen. nov. as Aggregatibacter actinomycetemcomitans comb. nov. The
species of the genus Aggregatibacter are independent of X factor and
variably dependent on V factor for growth in vitro. Norskov-Lauritsen
N, Kilian M (2007)

121

122

PORPHYROMONAS GINGIVALIS:
It is a Gram negative, anaerobic, non motile, asaccharolytic rods
that usually exhibit coccal to short rod morphologies.
P. gingivalis is a member of the much investigated black
pigmented Bacteroides group. Initially they were grouped into a
single species, B. melaninogenicus (Bacterium melaninogenicum,
Burdon 1928).

123

TANNERELLA FORSYTHIA
Third consensus periodontal pathogen, B. forsythus, was first
described in 1979 (Tanner et al. 1979) as a fusiform
Bacteroides.
The organism is a Gram negative, anaerobic, spindle shaped,
highly pleomorphic rod.
B. forsythus was detected more frequently and in higher
numbers in active periodontal lesions than inactive lesions (Dzink
et al 1988).
This species has been shown to produce trypsin like
proteolytic activity (BANA test positive, Loesche et al 1992)
and induce apoptotic cell death (Arakawa et al 2000).
124

SPIROCHETES
These are Gram negative, anaerobic, helical shaped, highly motile
microorganisms that are common in many periodontal pockets.
Clearly, a spirochete has been implicated as the likely
etiologic agent of acute necrotizing ulcerative gingivitis
(Listgarten & Socransky 1964).

The organism has been considered as possible periodontal


pathogens since the late 1800s and in the 1980s.

Difficulty in distinguishing individual species. At least 15


species of subgingival spirochetes have been described.
125

T. denticola was found to be more common in periodontally


diseased than healthy sites (Haffajee et al 1998, Yuan et al
2001).
These were the most frequently detected spirochetes in
supra and subgingival plaques of periodontitis patients.
Pathogen related oral spirochetes (PROS) were also shown
to have the ability to penetrate a tissue barrier in in vitro
systems (Riviere et al 1991).

126

PREVOTELLA INTERMEDIA/PREVOTELLA
NIGRESCENS
P. intermedia is the second black pigmented Bacteroides to
receive considerable interest in pathogenesis of chronic
periodontitis.
It is a Gram negative, short, round-ended anaerobic rod.
They have been shown to be particularly elevated in acute
necrotizing ulcerative gingivitis (Loesche et al 1982), and also in
certain forms of periodontitis (Herrera et al 2000, Papapanou et
al 2000).
127

This species appears to have a number of virulence properties


exhibited by P. gingivalis and was shown to induce mixed
infections. (Hafstrom & Dahlen 1997).
It has also been shown to invade oral epithelial cells in vitro
(Dorn et al 1998).
Strains of P. intermedia that show identical phenotypic
traits have been separated into two species, P. intermedia and P.
nigrescens (Shah & Gharbia 1992).

128

FUSOBACTERIUM NUCLEATUM

F. nucleatum is the type species of the genus Fusobacterium,


which belongs to the family Bacteroidaceae.. The name Fusobacterium
has its origin in fusus, a spindle; and bacterion, a small rod: thus, a
small spindle-shaped rod.
Gharbia and Shah (1990) divided Fusobacterium species into four
subspecies: subspecies nucleatum, polymorphum, fusiforme, and

animalis.
This species is the most common isolate found in cultural
studies of subgingival plaque samples comprising app. 7-10% of
total isolates. (Moore et al 1985).
The species can induce apoptotic cell death in mononuclear
and polymorphonuclear cells (Jewett et al 2001).
Acts as microbial bridge facilitating coaggregation
129
between early and Late colonizers.

CAMPYLOBACTER RECTUS
C. rectus is a Gram negative, anaerobic, short, motile vibrio. The
organism is unusual in that it utilizes H2 or formate as its energy
source.
It was first described as a member of the vibrio
corroders, eventually shown to include members of a new genus
Wolinella and Eikenella corrodens.
It was found in higher numbers in disease sites as compared
with healthy sites and more in sites exhibiting active periodontal
destruction.(Rams et al 1993).
Like A. actinomycetemcomitans, C. rectus has been shown to
produce a leukotoxin. These are the only two oral species known
to possess this characteristic (Gillespie et al 1992).

130

EIKENELLA CORRODENS
E. corrodens is a Gram negative, capnophilic, asacharolytic,
regular, small rod with blunt ends.
This species was found more frequently in sites of periodontal
destruction as compared with healthy sites and higher levels in active
sites (Tanner et al 1987).
In tissue culture system, E. corrodens has been shown to
stimulate the production of matrix metalloproteinase (Dahan et al
2001) and IL-6 and IL-8 (Yumoto et al 1999).
131

PEPTOSTREPTOCOCCUS MICROS
P. micros is a Gram positive, anaerobic, small, asaccharolytic
coccus.
Two genotypes can be distinguished with the smooth
genotype being more frequently associated with periodontitis
lesions than the rough genotype (Kremer et al. 2000).
P. micros was found to be in higher numbers at sites of
periodontal destruction as compared with healthy sites
(Papapanou et al 2000, Riggio et al 2001).
132

SELENOMONAS SPECIES
The selenomonas spp. are Gram negative, curved,
saccharolytic rods and may be recognized by their curved shape,
tumbling motility and, in good preparations, by the presence of a
tuft of flagella inserted in the concave side.
Moore et al (1987) described six genetically and
phenotypically distinct groups isolated from oral cavity and
found at a higher proportion of shallow sites (PD>4mm) in chronic
periodontitis.
133

EUBACTERIUM SPECIES
Certain Eubacterium species have been suggested as possible
periodontal pathogens due to their increased levels in disease
sites. (Moore et al 1985).
E. nodatum, Eubacterium brachy and Eubacterium timidum
are Gram positive, strictly anaerobic, small somewhat
pleomorphic rods.
Some of these species elicited elevated antibody responses
in subjects with destructive periodontitis. (Martin et al 1988)

134

PATHOGENS STRENGTH OF
RELATIONSHIP WITH DISEASE

135

GINGIVITIS
The microbial load at diseased sites is greater, with
approximately 104 to 106 bacteria.

The microbiota of chronic gingivitis (plaque induced)


consist of app. Equal proportions of gram positive (56%) and gram
negative (44%) species, as well as facultative (59%) and
anaerobic (41%) microorganisms.

Pregnancy associated gingivitis is accompanied by


increases in steroid hormones in crevicular fluid and dramatic
increases in levels of P. intermedia, which uses the steroid as
growth factors

136

CHRONIC PERIODONTITIS
Cultivation of plaque microorganisms from sites of chronic
periodontitis reveals high percentages of anaerobic (90%) and
gram negative (75%) bacterial species.
Certain gram-negative bacteria with pronounced virulence
properties have been strongly implicated as etiologic agents
(e.g. P. gingivalis and Tannerella forsythensis).

137

LOCALIZED AGGRESSIVE PERIODONTITIS

The microflora of subgingival biofilms from patients with


LAP is similar to that of patients with chronic periodontitis and
is predominantly composed of gram negative, capnophilic, and
anaerobic rods.
On a percentage basis, the most numerous isolates are
several species from the genera Eubacterium, A. naeslundii, F.
nucleatum, C. rectus, and Veillonella parvula.
Actinobacillus actinomycetemcomitans plays a causative
role in LAP, especially in cases in which patients harbor highly
leukotoxic strains of the organism.
However, some populations of patients with LAP do not
harbor A. actinomycetemcomitans, and in still others P.
gingivalis may be etiologically more important.
138

GENERALIZED AGGRESSIVE
PERIODONTITIS
The subgingival flora in patients with generalized
aggressive periodontitis resembles that in other forms of
periodontitis.
The predominant subgingival bacteria in patients with
generalized aggressive periodontitis are P. gingivalis, T.
forsythensis A. actinomycetemcomitans, and Campylobacter
species.

139

NECROTIZING ULCERATIVE
GINGIVITIS/PERIODONTITIS
The majority of the spirochetes (treponemes)
associated with necrotizing ulcerative gingivitis are
uncultivable, but it is clear that they constitute a very
large and diverse group.
More than 50% of the isolated species were strict
anaerobes with P. gingivalis and F. nucleatum accounting for
7-8% and 3.4%, respectively.

140

PERIODONTAL ABSCESSES
The bacteria isolated from abscesses are similar to those
associated with chronic and aggressive forms of periodontitis.
An average of approximately 70% of the cultivable flora in
exudates from periodontal abscesses are gram-negative and
about 50% are anaerobic rods.
Periodontal abscesses revealed a high prevalence of the
following putative pathogens: F. nucleatum (70.8%), P. micros
(70.6%), P. intermedia (62.5%), P. gingivalis (50.0%), and T.
forsythensis (47.1%).
Enteric bacteria, coagulase-negative staphylococci, and
Candida albicans have also been detected.
141

PERIIMPLANTITIS
Studies have shown that microbiota associated with
periimplantitis are comparable to that of periodontitis (high
proportion of anaerobic gram negative rods, motile organisms,
and spirochetes).
Species such as A. actinomycetemcomitans, P. gingivalis, T.
forsythia, P. micros, C. rectus, Fusobacterium, and
Capnocytophaga are often isolated from failing sites.
Other species such as Pseudomonas aeruginosa,
enterobacteriaceae, Candida albicans and staphylococci, are also
frequently detected around implants.
142

VACCINES
Three types of vaccines were employed for the control of
periodontal diseases. These included vaccines prepared from pure
cultures of streptococci, and other oral organisms, autogenous
vaccines, and stock vaccines such as Van Cotts vaccine,
Goldenbergs vaccine or Inava Endocorps vaccine.
These vaccines were administered systemically or locally in the
periodontal tissues.
Autogenous vaccines were prepared from the dental plaque of
patients with destructive periodontal diseases.
Plaque samples were removed from the diseased site, sterilized
by heat, and/or by immersion in iodine or formalin solutions, then
re-injected into the same patient, either in the local periodontal
lesion or systemically.
Proponents of all three techniques claimed great efficacy for the
vaccination methods employed, while others using the same
techniques were more sceptical.

143

SPECIFIC BACTERIAL BEHAVIOUR IN BIOFILM:


ANTIBIOTIC RESISTANCE
Microorganisms in biofilm are 1000 to 1500 times more
resistant to antibiotics than in their planktonic stage
The mechanism of this increased resistance differs from
species to species, from antibiotic to antibiotic, and for
biofilm growing in different habitats

RESISTANCE OF BACTERIA TO ANTIBIOTICS IS


AFFECTED BY THEIR
Nutritional status
Growth rate
Temparature
pH
Prior exposure to subeffective concentration of anti
microbial agents

144

Also slower growth of bacterial species in biofilm


is another important mechanism of antibiotic
resistance

Biofilm matrix although not significant barrier in


itself to diffusion of antibiotics but have certain
properties to resist diffusion

Biofilm act as ion-exchange resin removing


Some
antibiotics
such
as Macrolide which are
antibiotics
from
solution
positive charged but hydrophobic are unaffected
by this process
145

Also extracellular enzymes such as lactamases,


formaldehyde lyase and formaldehyde
dehydrogenase may become trapped and concentrated in
the extracellular matrix thus inactivating some
antibiotics(especially positive charged hydrophilic
antibiotics)

Super-resistant bacteria have been identified within a


biofilm and these cells have multidrug- resistant pump
that can extrude antimicrobials from the cell

146

147

TRANSLOCATION AND
MECHANICAL DEBRIDEMENT
To reduce chance of intraoral transmission, one stage, Full
mouth disinfection has been introduced by Leuven group
in the 1990s
This strategy attempts to eradicate, or atleast suppress,
periopathogens in short time not only from the periodontal
pockets, but also from all their intraoral habitats(mucous
membrane, tongue, and saliva)

148

REFERENCES
1. Textbook of Microbiology- Anantnarayan
2. Carranzas clinical periodontology. 9th edition
3. Clinical Periodontology and Implant dentistry, Jan Lindhe, 4th edition.
Blackwell munksgaard.
4. PD Marsh: Plaque as a biofilm: pharmacological principles of drug
delivery and action in the sub- and supragingival environment. Oral
Diseases (2003) 9 (Suppl. 1), 1622
5. Anne. D. Haffajee & sigmund.S. Socransky. Microbial etiological
agents of destructive periodontal diseases. Periodontology 2000, Vol.
5, 1994, 78-1
6. Tatsuj Nishihara & Takeyoshi koseki. Microbial etiology of
Periodontitis. Periodontology 2000, Vol. 36, 2004, 1426.