Microbiology

aspect in
endodontics
 Terminology

 Colonization : the establishment of bacteria or

orther microorganism in a living host.
 Infection : damage the host and produce clinical
signs and symptom
 Pathogenicity : The capacity of organisms to
produce disease within a particular host
 Virulence : the degree of pathogenicity in a host
under defind circumstance
State of disease Spread of infection

No.&Virulence of bacteria Associated anatomical structure

Abscess
formation
PA Pathology

Host defense

Status of host defensive system

Entries of bacteria to
the pulp system
•Caries
•Periodontal disease
•Trauma and restoration leakage
•Anachoreasis
Dental caries
Facultative gram positive
bacteria
Propionibacterium,
Eubacteruim, Arachnia,
Lactobacilli, Bifidobacterium ,
Actinomyces
Some of gram negative
bacterial such as Bacteroides

Hoshino et al 1985
DENTAL CARIES

 the most common pathway to the root canal

system for microbes. When the tooth is
intact, enamel and dentin protect it against
invasion of the pulp space.
 As caries approaches the pulp, reparative
dentin is laid down to avert exposure, but this
rarely can prevent microbial entry without
caries excavation
Dentinal tubules
 1 to 4 μm in diameter,
 bacteria are less than 1 μm in diameter.
 the protective cementum layer is missing or if it has been
lost through trauma, the dentinal tubules may be
exposed and may serve as a pathway for microbial
invasion of the pulp space.
 Bacterial movement is restricted by
:outflow of dentinal fluid,
: odontoblastic processes,
: mineralized crystals
: macromolecules, including immunoglobulins in the
tubules.
•Accessory canal
•Furcation canal
•Lateral canal
•Apical foramen
•Exposed dentinal tubule

Anerobic bacteria  Gram negative rod,

spirochete
Inflammation and local necrosis have been
demonstrated in pulp adjacent to entry pathway.

Whole pulp tissue change

due to periodontal disease
 Necrotic
pulp

Periodontal lesion involve apical foramen

Guldenor et al 1985
Pulp exposure due to trauma give access to
oral bacteria, this will cause bacterial invasion
to the pulp  inflammation

Pulp necrosis

Kakehashi et al 1965
Laboratory experiments indicate that bacteria
can enter through even minor crack in enamel
or dentine.

Love et al
1996
Dentinal tubules exposed by tooth fracture
during cavity preparation or marginal leakage
are the potential pathway.

Bender & Seltzer 1959

Smulson & Sieraski 1989
Anachoresis

“Blood borne bacteria is

preferentially localized in
areas of inflammation.”

Burke & Knigton 1960

Gier & Mitchell 1968

Intravenous bacterial injection into bloodstream could

be demonstrated in pulp that were inflamed due to
deep cavity preparation and chemical irritation.
 Polymicrobial

Microorganism

Endodontics failure
Pulpal and periapical
disease
In 1890 W.D. Miller, the father of oral microbiology, was the first
investigator to associate the presence of bacteria with pulpal disease.
A classic study published in 1965 by Kakehashi et al
Polymicrobial

 the number of microorganisms detected in

endodontic infections increased to a range of
three to 12 organisms per infected root canal
associated with an apical lesion

 A positive correlation exists between the number

of bacteria in an infected root canal and the size
of periradicular radiolucencies
 Strict anaerobes: function at low oxidation-reduction
potential and grow only in the absence of oxygen, but
they vary in their sensitivity to oxygen.
 Obligate anaerobic bacteria lack the enzymes superoxide
dismutase and catalase. Some species of bacteria are
microaerophilic; they can grow in the presence of oxygen,
but they derive most of their energy from anaerobic
energy pathways.
 Facultative anaerobic bacteria :can grow in the presence
or absence of oxygen.
 Obligate aerobic bacteria : have both superoxide
dismutase and catalase and require oxygen for growth
Type of microorganisms found in
endodontic Infections
ตาราง 2

Pisano and
 Failed Endodontic Treatment

 Enterococcus faecalis has been the predominant

microbe in canals undergoing retreatment

 E. faecalis was found in 77% of cases, confirming

that this microbe is the most prevalent species in
failed endodontic treatment
Sundqvist 1998
Bacterial virulence factors

Newman, M. B., H. H. Takei,

Type of microorganisms found in
endodontic
 Aerobes
Infections
 Streptococcus sp.: S.mitis, S.salivarius
 Anaerobic streptococci : Peptostreptococcus
 Enterococci: E. faecalis
 Bacteroides sp.: Porphyromonas, Prevotella
 Provotella nigrescens
 Actinomyces
 Fungi: Candida albicans
 Fusobacteria
 Spirochetes
 Biofilm
Primary endodontic infection

Anaerobic bacteria

Prevotella,Porphyromonas, Actinomyces,Peptostrept
Tanerella, Fusobacterium, ococcus, Eubacterium,
Dialister, Camphylobactor, Filifactor,
Treponema Psudoramibactor
Black pigmented bacteria

Prevotella

Bacteroides

Porphyromonas
Black pigmented bacteria

In 1980, Griffee et al reported that B.melaninogenicus was

found to be significantly related to pain, sinus tract formation,
and foul odor.

Griffee et al 1980
Black pigmented bacteria

 Prevotella  Porphyromonas
P.intermedia P.endodontalis
P.nigrescense P.gingivalis
P.tannerae
P.multisaccharivorax
They seem to play important role in
etiology of both acute and chronic
apical periodontitis.

Siqueira et al 2001
Sundqvist et al 1989
Dougherty et al 1998
Fusobacterium nucleatum
Gram negative obligate nonmotile anaerobe bacteria.

Most common in symptomatic infection and abscess or

excarcerbation lesion than asymptomatic infection.

5 subspecies of F.nucleatum have been found and different

in genetic data but no study found that which subspecies
have more virulence factor.

Different type of subspecies are found in the same root

canals.

Moraes et al 2002
Siqueira et al 2005
Spirochete bacteria
Although spirochetes have been frequently observed in samples
by microscopy, they had never been identified to the species
level.

The application of molecular diagnosis to identification of spiral

bacteria has been overlooked the culture techniques.
All oral spirochetes are genus Treponema .

They can be classified in 2 group; saccharolytic and saccharolytic.

T.denticola, T.sokranskii have been detected in both symptomatic

and asymptomatic lesion.

Dewhirst et al 2000
Baumgartner et al 2007
Rocas et al 2003
Secondary endodontic infection

If microorganisms are allowed to remain at the time

of filling , there is increased risk of adverse outcome
of the endodontic treatment

Sjogren et al 1997
Waltimo et al 2005
Secondary endodontic infection

Create both excellent apical and

coronal seal.

Prevent bacterial nutrient

regain in to the canal.
Microbial in root filled teeth

Unlike primary infection, a more restricted group of

microbial species has been found in
persistent/secondary infection .

The prevalence of enterococci has been found in

all studies that investigated flora in root-filled
teeth.

“ Enterococcus feacalis “
Microbial in root filled teeth

Recently findings from molecular studies have also

suggested that some anaerobic species commonly
found in primary infection.

T.forsythia, P.alactolyticus, F.acolis, D.pnuemosintes

Siqueira et al 2004,2005
Microbial in root filled teeth

Bacteria are secondary invaders that can gain entry in

to due to a breach in the aseptic chain during
intracanal intervention.

P.aeruginosa, Staphylococcus

Ranta et al 1988
Siqueira et all 2002
E.feacalis in secondary
infection

Facultative anaerobie, Gram

positive coccus.

This species has been found in low prevalence value in case

primary infection and more relate in asymptomatic cases than
symptomatic cases.

Rocas et al 2005
E.feacalis in secondary
infection
Virulence factor

Lytic enzyme, cytolysin, gelatinase,

hyaluronidase, pheromone, lipotheichoic
acid, adhesion molecules.

But cannot be clarified

what factor plays role
in pathogenesis. Kayaoglu et al 2004
E.feacalis in secondary
infection

Why E.feacalis can

survive in root filled teeth?
 E.feacalis in secondary
infection
Studies have revealed that E.feacalis has ability to
penetrate far into dentinal tubules that can escape
from intracanal instrumentation and irrigants.

Haapasalo et al 1989
Siqueira et al 1996
E.feacalis in secondary
infection
E.feacalis has been shown to be able to form biofilms in
root canals and this ability can be important for
bacterial resistance and persistence in the
instrumented canals.

Distel et al 2002

The ability to resist high pH value seems to be related to

functional proton pump . E.feacalis is resistant to
calcium hydroxide.

Evans et al 2002
 E.feacalis in secondary
infection

They have the ability to survive in environments in

scarcity of nutrients and to flourish when the nutrient
source is reestablished and has a capacity to recover in
root canal treated teeth for 12 months without nutrients.

Figdor et al 2003
Sedgley et al 2005
Fungi in secondary infection
The occurrence of yeasts were taken from samples that
not responding in favorably to conventional treatment
(72% of cases ).

Waltimo et al 1997

Candida albicans was the most common species.

Fungi in secondary infection
By the new detection technology, C.albicans was
detected in primary infection in 21% too.

However the finding indicates that yeasts may be

present in low number at the start of treatment, and
they may reach higher proportion during root canal
procedures .

Buamgartner et al 2000
Fungi in secondary infection
It is also possible that yeasts from oral cavity gain
access to root canal as contaminant during
endodontic procedures.

Siren et al 1997

Or they can overgrow after inefficient intracanal

antimicrobial procedures, which can cause imbalance
in microbiota.

Siqueira et al 2004
Fungi in secondary infection
Virulence factor

Dentino phillic microorganism due to its ability

to colonize and invade to dentine by their
hyphae.
Resist to some intracanal medication such as
calcium hydroxide.
Release hydrolytic enzyme and can form
monoinfection biofilm in root canals.

Sen et al 1997
Waltimo et al 1999,1997
Matusow et al 1981
Biofilms
Definition
The colonization and proliferation of
microorganisms at surface and solution
interface; especially problematic in the
small-bore water lines of dental unit.
AAE,2004
SEM of bacterial cells
arranged in a biofilm

Siquera 2001
1. Surface conditioning
2. Adhesion of ‘ pioneer ’ bacteria
3. Secondary colonizers
4. Fully functioning biofilm
1. A cooperative “consortia” of species
2. Biofilms grow and deattachment
A cooperative “consortia” of
species
Biofilms grow and spread
 Cell-cell communication

 Communicate with one another in biofilm

communities via small diffusible molecules.
 Adapt & survive various environment stresses.
 Regulate expression of gene
 Ability to cause disease
Benefits

 A broader habitat range for growth

 A more efficient metabolism
 Increased resistance to stress and
antimicrobial agent
 Enhanced virulence
Microbial control in biofilm

Bacteria in biofilm form is more resistance to anti-

microbial agent than planktonic form.

Larsen et al 2002
Irrigants for microbial
control
•Sodium hypochlorite
•Combination of sodium hypochlorite and
chlorhexidine
•Chlorhexidine
•Povidone iodine

Spratt et al 2001
Er:YAG LASER

Er:YAG lasers had an anti-

biofilm effect at a low energy
and could reduce numbers of
the 6 species of biofilm-
forming cells examined.

Noiri et al 2008
Photodynamic with methylene blue

Photodynamic therapy (PDT) was developed as a

therapy for cancer.
Activated by light of the appropriate wavelength to
generate singlet oxygen and free radicals that are
cytotoxic to cells of the target tissue.
 Treatment of endodontics
infection
 Debridement of the root canal system
 Incision and drainage
 Intracanal medication
 Analgesics and antibiotics
 Follow up