The microbial challenge in periodontitis

Apple- and Hop-Polyphenols Protect Periodontal Ligament Cells Stimulated With Enamel Matrix Derivative FromPorphyromonas gingivalis

BACKGROUND

Enamel matrix derivative (EMD) is a tissue regenerative agent used clinically as an adjunct to periodontal surgery. It was previously demonstrated that Porphyromonas gingivalis, a periodontal pathogen, significantly diminished the efficacy of EMD with periodontal ligament (PDL) cells through the proteolytic actions of Arg- and Lys-gingipains (Rgp and Kgp). Thus, antiproteolytic supplements are considered clinically desirable for effective periodontal regenerative therapies. In the present study, we examined apple- (AP) and hop-polyphenols to determine their ability to protect EMD-stimulated PDL cells from P. gingivalis.

METHODS

AP, apple condensed tannin (ACT), hop bract polyphenol (HBP), high and low molecular weight fractions of HBP (HMW-HBP and LMW-HBP), and epigallocatechin gallate (EGCg) were used. PDL cells were grown on EMD-coated dishes and infected with P. gingivalis, and cellular migration and proliferation were evaluated with an in vitro assay of wound healing assay in the presence or absence of the polyphenols.

RESULTS

Each polyphenol significantly enhanced the viability of PDL cells infected with P. gingivalis, whereas only EGCg demonstrated cytotoxicity. Further, all polyphenols significantly inhibited Rgp activity, with AP, ACT, and HBP more effective toward Kgp. P. gingivalis markedly diminished the migration and proliferation of EMD-stimulated PDL cells, whereas the addition of AP, ACT, HBP, and HMW-HBP significantly protected the cells from bacterial cytotoxicity. In contrast, EGCg and LMW-HBP did not show protective effects.

CONCLUSION

These results suggest that AP, ACT, AP, HBP, and HMW-HBP protect EMD-stimulated PDL cells from P. gingivalis and may be therapeutically useful supplements for EMD therapy.

The use of surrogate variables to reflect long-term tooth survivability

Clinical parameters used to monitor periodontal patients are usually measures of the disease process. They are considered surrogate variables because changes in their status are interpreted to have an impact on the ultimate goal of periodontal therapy, which is tooth retention. However, their ability to reflect tooth survivability has been questioned because there is a lack of long-term data to validate that stable or improved surrogates result in reduced tooth loss. Therefore, to clarify the utility of employing surrogates to reflect long-term tooth retention, a number of issues related to their use are discussed in this commentary: phraseology, benefits and shortcomings, biologic credibility, and their previous successful utilization in monitoring the effects of therapy. This commentary supports the reasonableness of using surrogates to monitor periodontal status and suggests that a combination of surrogates that represent "periodontal clinical health" should be considered a true endpoint of periodontal therapy, since this outcome provides a condition conducive to tooth retention.

Lipopolysaccharide-binding protein down-regulates the expression of interleukin-6 by human gingival fibroblast

BACKGROUND

Lipopolysaccharide-binding protein (LBP) participates in the interaction of lipopolysacchaide (LPS) with CD14 to modulate the expression of cytokines. Human gingival fibroblast may actively participate in LPS-induced immuno-inflammatory responses through CD14, toll-like receptor (TLR) superfamily, MD-2 and related adaptive proteins, leading to the expression of cytokines.

OBJECTIVES

The present in vitro study aimed to investigate the possible effect of LBP and E. coli LPS interaction on the expression of cellular LPS receptors and IL-6 by human gingival fibroblast.

METHODS

The mRNA expression of CD14, LBP, TLR-2, TLR-4, MD-2 and IL-6 in human gingival fibroblast explants was detected by reverse transcriptionpolymerase chain reaction (RT-PCR) in the presence or absence of E. coli LPS and recombinant human LBP (rhLBP), while IL-6 peptides were analyzed by ELISA and immunohistochemistry, respectively.

RESULTS

Human gingival fibroblast could constitutively express CD14, MD-2 and IL-6 mRNAs, but not TLR-2, TLR-4 and LBP mRNAs. E. coli LPS induced the messages expression of MD-2, TLR-2 and -4. The expression of both IL-6 message and peptide was up-regulated by E. coli LPS in a dose dependent manner. Whereas rhLBP could significantly down-regulate the expression of both mRNAs and peptides of CD14 and IL-6 but not MD-2 signals in the presence or absence of E. coli LPS. The up-regulated expression of TLR-2 and -4 by E. coli LPS no longer existed in the presence of rhLBP.

CONCLUSIONS

This study suggests that LBP may down-regulate the expression of IL-6 by human gingival fibroblast. Further studies are warranted to clarify the molecular mechanisms of LBP in regulation of cytokine expression by host cells and to elaborate the relevant clinical implications.

Antimicrobial peptides in the oral environment: expression and function in health and disease

The oral cavity is a unique environment in which antimicrobial peptides play a key role in maintaining health and may have future therapeutic applications. Present evidence suggests that alpha-defensins, beta-defensins, LL-37, histatin, and other antimicrobial peptides and proteins have distinct but overlapping roles in maintaining oral health and preventing bacterial, fungal, and viral adherence and infection. The expression of the inducible hBD-2 in normal oral epithelium, in contrast to other epithelia, and the apparent differential signaling in response to commensal and pathogenic organisms, provides new insights into innate immunity in this body site. Commensal bacteria are excellent inducers of hBD-2 in oral epithelial cells, suggesting that the commensal bacterial community acts in a manner to benefit the overall innate immune readiness of oral epithelia. This may have major significance for understanding host defense in the complex oral environment.

Sequence variations in rgpA and rgpB of Porphyromonas gingivalis in periodontitis

OBJECTIVE

The aim of the present study was to determine sequence variations in the active centre of the Arg-X-specific protease encoding genes rgpA and rgpB of clinical Porphyromonas gingivalis isolates and to analyse their prevalence in periodontitis patients before and 3 months after mechanical periodontal therapy.

BACKGROUND

Genetic diversity at nucleotides 281, 283, 286 and 331 has been shown to result in amino acid substitutions in the catalytic domain of RgpA and RgpB that affect the substrate specificity and thus may influence the efficacy of Arg-X-protease specific inhibitors.

METHODS

Sequence analysis of rgpA and rgpB genes in clinical P. gingivalis strains isolated from subgingival plaque samples of 82 periodontitis patients before and 3 months after mechanical supra- and subgingival debridement was performed.

RESULTS

No specific variation within the rgpA sequence was observed. However, the rgpB sequence in the region of the active centre showed five different rgpB genotypes, which were named NYPN, NSSN, NSSK, NYPK and DYPN according to the derived amino acid substitution. Porphyromonas gingivalis genotype NYPN was detected in 27 patients (32.9%) before and in 8 patients (9.8%) after therapy, NSSN in 26 (31.7%) and 10 (12.2%), NSSK in 22 (26.8%) and 2 (2.4%), NYPK in 5 (6.2%) and 1 (1.2%), and DYPN in 1 patient (1.2%) and 0 patients (0%), respectively. Only one patient (1.2%) harboured two P. gingivalis rgpB genotypes (NSSK/NYPN) before treatment; these were no longer detected after therapy.

CONCLUSION

The results indicate that five rgpB genotypes are maintained in natural populations of P. gingivalis. These data may be of importance with regard to the development of specific rgpB inhibitors.

Periodontitis in humans and non-human primates: oral-systemic linkage inducing acute phase proteins

BACKGROUND

The acute phase response (APR) represents a systemic counterpart to the localized inflammatory response. This report describes patient-oriented and non-human primate model studies to determine the effect of periodontal disease on systemic acute phase proteins (APP).

METHODS

Patient-oriented studies included comparison of the levels of APP, using enzyme-linked immunosorbent assay (ELISA), with the presence and severity of periodontitis in localized chronic periodontitis (LCP), generalized aggressive periodontitis (GAP), and Sjogren's syndrome (SS) patients. The non-human primate experiments evaluated the serum level of APPs under natural conditions, following mechanical hygiene, experimental gingivitis, and during ligature-induced periodontitis.

RESULTS

Analysis of the LCP population showed what appeared to be a threshold of periodontal disease severity required for elevating the C-reactive protein (CRP) and haptoglobin (HG). The results demonstrated a significant elevation in CRP in the GAP versus the control groups, as well as lower levels of all mediators in healthy non-smokers (HNS) versus smokers (HS), suggesting that these systemic inflammatory markers were altered in response to challenge by noxious materials from smoking. Significantly different levels of CRP, HG, and alpha1-antiproteinase were noted in the SS patients suggesting that the autoimmune aspects of Sjögren's syndrome may impact upon oral health and systemic responses. Parallel evidence was also obtained from the primate studies. Providing mechanical oral hygiene, which significantly lowered clinical inflammation and bleeding of the gingiva, decreased the serum APP levels. Both CRP and fibrinogen were significantly elevated during progressing periodontitis, which also appeared to have an impact on serum lipids and lipoproteins.

CONCLUSIONS

These findings supported results relating chronic oral infections and the inflammation of periodontitis as contributors to and/or triggers for systemic inflammatory responses. Finally, similarities in the clinical and microbiological parameters of gingival inflammation and periodontitis between humans and non-human primates was extended to identification of changes in serum APP in the non-human primates that appeared to be in direct response to the induction of progressing periodontitis. These systemic changes provide additional evidence for the biological plausibility of periodontal infections contributing to various systemic diseases.

Porphyromonas gingivalis lipopolysaccharide displays functionally diverse interactions with the innate host defense system

Periodontitis is a bacterially induced chronic inflammatory disease and a major cause of tooth loss in the world. The tissue damage and alveolar bone resorption characteristic of the disease are believed to be due to a destructive innate host response to a pathogenic subgingival biofilm. Porphyromonas gingivalis, a Gram-negative bacterium, is a member of this mixed microbial community that has been designated an etiologic agent of periodontitis. The innate host response to lipopolysaccharide (LPS) obtained from P. gingivalis is unusual in that different studies have reported that it can be an agonist for Toll-like receptor (TLR) 2 as well as an antagonist or agonist for TLR4. In addition, human monocytes respond to this LPS by secreting a variety of different inflammatory mediators, while endothelial cells do not. We have examined highly purified preparations of P. gingivalis LPS and found that they activate both TLR2 combined with TLR1 and TLR4 in transiently transfected human embryonic kidney (HEK) 293 cells. We have further demonstrated that highly purified P. gingivalis LPS preparations contain at least 3 major different lipid A species. We speculate that P. gingivalis lipid A structural heterogeneity contributes to the unusual innate host response to this LPS and its ability to interact with different TLR molecules.

Genetic variation of a fimbrial protein from Porphyromonas gingivalis and its distribution in patients with periodontal diseases

Pg-II fim from various strains of Porphyromonas gingivalis was classified on the basis of each nucleotide sequence, while the distribution of Pg-II fim types in 141 subgingival plaque samples was analyzed using PCR assays. Pg-II fim was divided into two types as follows: strains OMZ409, HG405, 381, ATCC 33277 and BH18/10 (type 1) and strains OMZ314 and HW24D-1 (type 2). The presence of P. gingivalis was demonstrated in 2.8% of healthy subjects and 56.1% of patients with periodontal diseases, and Pg-II fim was detected in 91.8% of the P. gingivalis-positive subjects. We also analyzed the distribution of the Pg-II fim types among Pg-II fim-positive patients, with the following results: type 1 (38.2%), type 2 (56.4%) and types 1 and 2 (5.4%). These findings strongly suggest that P. gingivalis organisms possessing Pg-II fim type 2 was principally detected in patients with periodontal diseases.

Characterization of Actinobacillus actinomycetemcomitans isolated from young Chinese aggressive periodontitis patients

OBJECTIVE

This study characterized Actinobacillus actinomycetemcomitans isolates from young Chinese aggressive periodontitis patients.

METHODS

Subgingival plaque samples (two/subject) were collected from diseased subjects < 25 years old (n = 9, mean age 21.1 +/- 1.6 years) and age-matched periodontitis-free controls (n = 47, mean age 22.0 +/- 1.1 years). Selective and anaerobic culture were used. The serotype, leukotoxin gene (ltx) operon promoter and the cytolethal distending toxin (cdt) genes complex of the A. actinomycetemcomitans isolates were investigated. Effects of the isolates on non-keratinizing periodontal ligament epithelial cells monolayer were studied.

RESULTS

Diseased subjects had significantly higher full-mouth bleeding score (p = 0.002) and total viable counts from plaque samples (7.2 x 10(6) vs. 2.1 x 10(5) CFU/paperpoint, p < 0.005). A. actinomycetemcomitans was isolated from 67%/56% or 6%/4% of diseased or controls subject/sites, respectively (p < 0.001). The proportion of A. actinomycetemcomitans isolatable from aggressive periodontitis or periodontitis-free associated subgingival plaque was low (0.7% vs. 0.1%, p < 0.02). The serotype of the isolates was characterized. All isolates possessed 652-like ltx gene promoter and all but one serotype c isolate from a diseased patient had intact cdtABC genes. That particular strain appeared to confer the least cellular damages on periodontal ligament epithelial monolayer compared to others.

CONCLUSION

This preliminary study confirmed the notion of increased prevalence and quantity of A. actinomycetemcomitans associated with aggressive periodontitis in young patients. The overall ltx promoter and cdt characteristics of the A. actinomycetemcomitans isolates, however, were similar among the diseased and control groups. A strain lacking the cdtABC gene appeared to be less damaging to a periodontal ligament epithelial cell model. Further studies therefore are warranted to clarify the pathogenic role and potentials of A. actinomycetemcomitans in aggressive periodontitis.

Photodynamic therapy for periodontal diseases: State of the art

BACKGROUND

Photodynamic killing of periodontopathogenic bacteria may be an alternative to the systemic application of antibacterial drugs used in the treatment of periodontal diseases. Even though the method is still in the experimental stage, increasing bacterial resistance problems may promote the introduction of photodynamic therapy (PDT) into periodontal practice.

AIM

In this review a literature survey is given of PDT as seen from a periodontal perspective.

METHODS

In this review, the present knowledge and experience of PDT is summarized. Literature data are presented on drawbacks of conventional antibiotics, the mechanism of PDT, bactericidal effects of PDT as well as results of clinical efforts. The future prospects of the method are discussed.

RESULTS

The application of photosensitizing dyes and their excitation by visible light enables effective killing of periodontopathogens. Encouraging studies using PDT in periodontitis and in peri-implantitis are known.

CONCLUSION

Even though PDT is still in experimental stages of development and testing, the method may be an adjunct to conventional antibacterial measures in periodontology. Clinical follow-up studies are needed to confirm the efficacy of the procedure.

Stimulation of growth of Porphyromonas gingivalis by cell extracts from Tannerella forsythia

OBJECTIVE

In order to examine if Tannerella forsythia stimulates the growth of Porphyromonas gingivalis, an in vitro study was performed.

BACKGROUND

P. gingivalis and T. forsythia are often isolated simultaneously from active periodontitis sites, indicating that these bacteria somewhat interact in the periodontal environment. We reported previously that mixed infection of P. gingivalis and T. forsythia synergistically induced lesion formation in a murine abscess model, and gingipains of P. gingivalis played an important role in this synergism. One of the possible mechanisms of this synergism is growth promotion by coinfection of the two bacteria.

METHODS

Cell extracts of T. forsythia were added to the nutrition-decreased medium and the promotion of growth of P. gingivalis was examined.

RESULTS

Sonicated extract of T. forsythia stimulated growth of P. gingivalis in nutrition-decreased medium in a dose-dependent manner. Proteins appeared to be the nature of growth-promoting factor, and the cell extract of T. forsythia had no stimulating effect on the growth of P. gingivalis strain devoid of gingipain activities.

CONCLUSION

A product or a component of T. forsythia seemed to stimulate growth of P. gingivalis under nutrition-limited conditions. Gingipains are considered to play an important role in digestion or uptake of this growth-promoting factor. The interaction between T. forsythia and P. gingivalis in growth may be in part related with the synergistic virulence in a murine model.

Immunohistological analysis of Tannerella forsythia-induced lesions in a murine model

Tannerella forsythia has been implicated as a defined periodontal pathogen. In the present study a mouse model was used to determine the phenotype of leukocytes in the lesions induced by subcutaneous injections of either live (group A) or nonviable (group B) T. forsythia. Control mice (group C) received the vehicle only. Lesions were excised at days 1, 2, 4, and 7. An avidin-biotin immunoperoxidase method was used to stain infiltrating CD4+ and CD8+ T cells, CD14+ macrophages, CD19+ B cells, and neutrophils. Hematoxylin and eosin sections demonstrated lesions with central necrotic cores surrounded by neutrophils, macrophages and lymphocytes in both group A and group B mice. Lesions from control mice exhibited no or only occasional solitary leukocytes. In both groups A and B, neutrophils were the dominant leukocyte in the lesion 1 day after injection, the numbers decreasing over the 7-day experimental period. There was a relatively low mean percent of CD4+ and CD8+ T cells in the lesions and, whereas the percent of CD8+ T cells remained constant, there was a significant increase in the percent of CD4+ T cells at day 7. This increase was more evident in group A mice. The mean percent of CD14+ macrophages and CD19+ B cells remained low over the experimental period, although there was a significantly higher mean percent of CD19+ B cells at day 1. In conclusion, the results showed that immunization of mice with live T. forsythia induced a stronger immune response than nonviable organisms. The inflammatory response presented as a nonspecific immune response with evidence of an adaptive (T-cell) response by day 7. Unlike Porphyromonas gingivalis, there was no inhibition of neutrophil migration.

Keratinocyte growth factor-1 expression in healthy and diseased human periodontal tissues

OBJECTIVES

Keratinocyte growth factor-1 (KGF-1) is up-regulated in chronic inflammation and specifically stimulates epithelial cell proliferation by signaling through the epithelial-specific keratinocyte growth factor receptor (KGFR). We examined KGF-1 and KGFR protein and gene expression in healthy and diseased periodontal tissues.

METHODS

Tissues were collected from patients with periodontal health or disease, immediately frozen and stained for KGF-1 and KGFR protein expression. Laser capture microdissection of epithelial and connective tissue cells with reverse transcription-polymerase chain reaction (RT-PCR) examined KGF-1 and KGFR gene expression profiles and enzymatic digestion with heparitinase, chondroitinase ABC or pre-treatment with suramin examined epithelial surface molecule interactions with KGF-1.

RESULTS

In tissues collected from healthy patients, KGF-1 protein localized to areas of junctional and basal oral epithelial cells and was significantly increased in periodontal pocket epithelium (p<0.01) and in the oral epithelium (p<0.05) of disease-associated tissues. KGFR localized to the junctional and the parabasal cells of oral epithelium, with the relative staining intensity being increased in disease-associated pocket epithelium (p<0.05). Laser capture microdissection with RT-PCR confirmed KGF-1 and KGFR were specifically expressed by connective tissue and epithelium, respectively. KGF-1 localization to epithelial cells was largely eliminated by suramin pre-treatment, indicating interaction with the KGFR.

CONCLUSIONS

KGF-1 and KGFR proteins are expressed in healthy periodontal tissues but significantly increased in diseased periodontal tissues. We hypothesize up-regulation of KGF-1 and KGFR protein associated with disease regulates epithelial cell behavior associated with onset and progression of periodontal pocket formation.

Gingipains from Porphyromonas gingivalis W83 induce cell adhesion molecule cleavage and apoptosis in endothelial cells

The presence of Porphyromonas gingivalis in the periodontal pocket and the high levels of gingipain activity detected in gingival crevicular fluid could implicate a role for gingipains in the destruction of the highly vascular periodontal tissue. To explore the effects of these proteases on endothelial cells, we exposed bovine coronary artery endothelial cells and human microvascular endothelial cells to gingipain-active extracellular protein preparations and/or purified gingipains from P. gingivalis. Treated cells exhibited a rapid loss of cell adhesion properties that was followed by apoptotic cell death. Cleavage of N- and VE-cadherin and integrin beta1 was observed in immunoblots of cell lysates. There was a direct correlation between the kinetics of cleavage of N- and VE-cadherin and loss of cell adhesion properties. Loss of cell adhesion, as well as N- and VE-cadherin and integrin beta1 cleavage, could be inhibited or significantly delayed by preincubation of P. gingivalis W83 gingipain-active extracellular extracts with the cysteine protease inhibitor Nalpha-p-tosyl-l-lysine chloromethylketone. Furthermore, purified gingipains also induced endothelial cell detachment and apoptosis. Apoptosis-associated events, including annexin V positivity, caspase-3 activation, and cleavage of the caspase substrates poly(ADP-ribose) polymerase and topoisomerase I (Topo I), were observed in endothelial cells after detachment. All of the effects observed were correlated with the different levels of cysteine-dependent proteolytic activity of the extracts tested. Taken together, these results indicate that gingipains from P. gingivalis can alter cell adhesion molecules and induce endothelial cell death, which could have implications for the pathogenicity of this organism.

Temporal relationship between the occurrence of fresh noma and the timing of linear growth retardation in Nigerian children

BACKGROUND

Fresh noma (cancrum oris) occurs predominantly in children <4 years of age. The key risk factors are poverty, malnutrition and infections. Evolution from an intraoral inflammation to a grotesque oro-facial gangrene is very rapid.

OBJECTIVE

We assessed potential relationship between the occurrence of fresh noma and linear growth retardation (LGR) which is prevalent in deprived Third World infants/children between ages 3 and 30 months. LGR is attributed to malnutrition and chronic immunostimulation by environmental antigens.

DESIGN

Anthropometric evaluation of children (n = 91) with fresh noma, ages 0-8 years, in relation to US National Center for Health Statistics Reference values was carried out. Age-matched noma-free, poor village children (n = 151) from similar communities as noma cases, and elite urban children (n = 132) served as control groups. Heights and weights were measured and the height for age (HAZ), weight for age (WAZ) and weight for height (WHZ) scores calculated as indices of stunting, underweight and wasting respectively. Serum level of interleukin (IL)-18, a multifunctional cytokine, was also measured.

RESULTS

In the age groups 0-4 and 4-8 years, the percentages of noma children <-2.0SD were 91% and 67% respectively. The corresponding values for the village children were 37% and 24% and significantly different (P < 0.001) from the noma group. Only 7% of the elite children aged 4-8 years were stunted. Low body weight and wasting were prominent features of village and noma groups, but more marked in the latter. Associated with noma was a profound increase (P < 0.001) in IL-18 in comparison with urban controls, and a 34% non-statistically significant increase relative to the village control group. Among other functions, IL-18 induces several pro-inflammatory cytokines and the matrix metalloproteinases, influences long bone growth, and consequently may be relevant to growth retardation seen in poor village children and noma victims.

CONCLUSION

These results suggest that occurrence of fresh noma was probably programmed very early in life by malnutrition and chronic infections resulting from replacement of breast milk with contaminated, inferior substitutes. Although not investigated, we speculate that children with fresh noma might also be victims of intrauterine growth retardation as noma is most prevalent during the infantile phase of child growth which starts at mid-gestation and tails off at 4 years.

Inhibitory effects of Porphyromonas gingivalis fimbriae on interactions between extracellular matrix proteins and cellular integrins

Porphyromonas gingivalis is a predominant periodontal pathogen, whose fimbriae are considered to be a major virulence factor, especially for bacterial adherence and invasion of host cells. In the present study, we investigated the influence of fimbriae on the interactions between alphavbeta3- and alpha5beta1-integrins and their ligand extracellular matrix (ECM) proteins (vitronectin and fibronectin), using human alphavbeta3- and alpha5beta1-integrin-overexpressing CHO cell lines (CHOalphavbeta3 and CHOalpha5beta1, respectively). P. gingivalis was found to have significantly greater binding to CHOalphavbeta3 and CHOalpha5beta1 than to control cells, whereas a fimbria-deficient mutant showed negligible binding to any of the tested cell lines. CHOalphavbeta3 and CHOalpha5beta1 cells attached to the polystyrene culture dishes in the presence of their ligand ECM proteins, while fimbriae markedly inhibited those attachments in a dose-dependent manner, with the highest dose of fimbriae achieving complete inhibition. In addition, the binding of vitronectin and fibronectin to CHOalphavbeta3 and CHOalpha5beta1 was inhibited by P. gingivalis cells. These results suggest that P. gingivalis fimbriae compete with ECM proteins for alphavbeta3- and alpha5beta1-integrins, and inhibit integrin/ECM protein-related cellular functions.

Prevalence of periodontal pathogens in dental plaque of children

Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, and Tannerella forsythensis have been implicated as the main etiological agents of periodontal disease. The purpose of this work was to estimate the prevalence of these organisms in plaque from children without gingivitis (group 1; n = 65) and from those with gingivitis (group 2; n = 53). Extracted DNA from plaque was subjected to two rounds of PCR targeting the 16S rRNA gene using both universal primers and species-specific primers. The results were as follows: group 1, P. gingivalis, 49%; A. actinomycetemcomitans, 55%; and T. forsythensis, 65%; group 2, P. gingivalis, 47%; A. actinomycetemcomitans, 59%; and T. forsythensis, 45%. T. forsythensis was detected more frequently in children with no gingivitis than in those with gingivitis (P = 0.03). There was no significant difference between the two groups with respect to the presence of P. gingivalis or A. actinomycetemcomitans in either group (P > 0.05). Logistic regression analysis revealed that the odds of a patient having gingivitis were 2.3 times greater in the absence of T. forsythensis. In conclusion, the results of this study have shown that the three pathogens can be detected in the dental plaque of healthy children and of those with gingivitis and that T. forsythensis is associated with dental plaque at sites with no gingivitis.

Porphyromonas gingivalis lipopolysaccharide contains multiple lipid A species that functionally interact with both toll-like receptors 2 and 4

The innate host response to lipopolysaccharide (LPS) obtained from Porphyromonas gingivalis is unusual in that different studies have reported that it can be an agonist for Toll-like receptor 2 (TLR2) as well as an antagonist or agonist for TLR4. In this report it is shown that P. gingivalis LPS is highly heterogeneous, containing more lipid A species than previously described. In addition, purification of LPS can preferentially fractionate these lipid A species. It is shown that an LPS preparation enriched for lipid A species at m/z 1,435 and 1,450 activates human and mouse TLR2, TLR2 plus TLR1, and TLR4 in transiently transfected HEK 293 cells coexpressing membrane-associated CD14. The HEK cell experiments further demonstrated that cofactor MD-2 was required for functional engagement of TLR4 but not of TLR2 nor TLR2 plus TLR1. In addition, serum-soluble CD14 effectively transferred P. gingivalis LPS to TLR2 plus TLR1, but poorly to TLR4. Importantly, bone marrow cells obtained from TLR2(-/-) and TLR4(-/-) mice also responded to P. gingivalis LPS in a manor consistent with the HEK results, demonstrating that P. gingivalis LPS can utilize both TLR2 and TLR4. No response was observed from bone marrow cells obtained from TLR2 and TLR4 double-knockout mice, demonstrating that P. gingivalis LPS activation occurred exclusively through either TLR2 or TLR4. Although the biological significance of the different lipid A species found in P. gingivalis LPS preparations is not currently understood, it is proposed that the presence of multiple lipid A species contributes to cell activation through both TLR2 and TLR4.

Effect of enamel matrix derivative on periodontal ligament cells in vitro is diminished by Porphyromonas gingivalis

BACKGROUND

Enamel matrix derivative (EMD) has been shown to possess a mitogenic effect to induce effective periodontal regeneration, however, it is unclear whether periodontal pathogens can modulate the effect of EMD. The present study examined the influence of Porphyromonas gingivalis on EMD-stimulated periodontal ligament (PDL) cells.

METHODS

P. gingivalis ATCC33277 and its mutants deficient in fimbriae (delta fimA) or gingipains (delta rgpA delta rgpB, delta kgp, and delta rgpA delta rgpB delta kgp) were employed. PDL cells were grown on EMD-coated dishes and infected with P. gingivalis wild strain or a mutant. Cell migration and proliferation were then evaluated with an in vitro wound healing assay. The expression of transforming growth factor-beta1 (TGF-beta1) and insulin-like growth factor I (IGF-I) mRNA by PDL cells was examined. Further, the degradation and phosphorylation of extracellular signal-regulated kinase 1 and 2 (ERK1/2) as well as paxillin in infected PDL cells were estimated using Western blot analysis.

RESULTS

P. gingivalis ATCC33277 inhibited the migration and proliferation of PDL cells on EMD-coated dishes, and the mutants delta fimA, delta rgpA delta rgpB, and delta kgp showed the same effects. Further, each of these organisms diminished the expression of TGF-beta1 and IGF-I mRNA, as well as the phosphorylation of ERK1/2 from EMD-stimulated PDL cells. In addition, total paxillin protein was markedly degraded by both the wild-type strain and each of the mutants except for delta rgpA delta rgpB delta kgp, which showed a negligible effect in all of the assays with EMD-stimulated PDL cells.

CONCLUSION

These results suggest that P. gingivalis diminishes the effect of EMD on PDL cells in vitro through a cooperative action of gingipains.

The in vivo expression of membrane-bound CD14 in periodontal health and disease

BACKGROUND

Membrane-bound CD14 (mCD14) is a myeloid differentiation antigen expressed on monocytes/macrophages and neutrophils. It is a key molecule responsible for the innate recognition of bacteria by host cells and functions as an important receptor for bacterial lipopolysaccharide. This study investigated the in vivo expression profile and levels of mCD14 in healthy and diseased gingival tissues.

METHODS

Gingival biopsies were obtained from 24 patients with chronic periodontitis, including 22 periodontal pocket tissues, 13 clinically healthy tissues, and 18 inflamed connective tissues (i.e., granulation tissues). Gingival biopsies from seven periodontally healthy subjects were used as controls. mCD14 was detected by immunohistochemistry.

RESULTS

mCD14 was detected in 21 of 22 periodontal pocket tissues and all other categories of tissues. The mCD14-positive cells were mainly confined to the gingival epithelium-connective tissue interface. The expression levels in periodontally healthy subjects were significantly higher than in the patients. Within the patients, clinically healthy tissues showed greater levels of mCD14 than periodontal pocket tissues and granulation tissues.

CONCLUSIONS

mCD14 was commonly expressed in both healthy and diseased gingival tissues and was predominantly confined to the epithelium-connective tissue interface. The positive relationship observed between mCD14 expression levels and periodontal health may imply that mCD14 is associated with favorable host responses to bacterial challenge and contributes to maintaining periodontal homeostasis.

Relationship between clinical parameters and cytokine profiles in inflamed gingival tissue and serum samples from patients with chronic periodontitis

OBJECTIVE

The purpose of the present study was to assess the relation between clinical parameters and concentrations of the key (IL-1beta, TNF-alpha, IL-2, IFN-gamma, IL-4, IL-10) cytokines, important in the initiation and progression of periodontal diseases, within inflamed gingival tissues and serum samples from patients with severe chronic periodontitis.

MATERIAL AND METHODS

Twenty-five patients with severe chronic periodontitis, who had sites with probing depths (PD) > 5 mm, and 25 periodontally healthy persons were included in the study. Clinical examinations including PD, clinical attachment loss, plaque index, and bleeding index were performed before periodontal treatment. Gingival tissue biopsies were collected from one active site of each patient and from healthy individuals, and blood samples were withdrawn on the day of tissue biopsy. The concentrations of cytokines were determined by an enzyme-linked immunosorbent assay, and the relationship between their profiles in situ and in circulation with clinical parameters was analysed.

RESULTS

The concentrations of IL-1beta, TNF-alpha, IL-2, IFN-gamma were, on average, significantly higher in serum samples and gingival tissue biopsies from periodontitis patients than in healthy controls. However, serum samples from both groups showed high individual variability of cytokine profiles, and no association between cytokine concentrations and clinical parameters of periodontitis was found. On the contrary, the levels of IL-4 and IL-10 in both kinds of samples obtained from patients and controls were generally low or even undetectable, and remained, on average, on the same level. However, the frequency of IL-4 (88% positive samples) and IL-10 (72%) was much higher in healthy gingival tissues. High concentrations of TNF-alpha, IFN-gamma and IL-2 and, especially, a high ratio of IL-1beta/IL-10 and TNF-alpha/IL-4 found in tissue biopsies from periodontitis patients, strongly correlated with the severity of periodontitis.

CONCLUSION

These results indicate that high variability of cytokine concentrations and low frequency of their detection in serum samples from periodontitis patients make these determinations useless for the detection of disease presence and/or its severity. In contrast, high absolute levels of IL-1beta, TNF-alpha, IL-2 and IFN-gamma and, especially their high ratios to IL-4 and IL-10 found in inflamed tissue biopsies, were closely associated with periodontal disease severity.

Microbiological diagnostic testing in the treatment of periodontal diseases

A variety of microbiological diagnostic tests are available for clinicians to use for evaluation of patients with periodontal disease. Each one has its own unique set of advantages and disadvantages, and probably the most useful information for the clinician can be obtained using a combination of the various analytic methods. The tests appear to have their greatest utility when used on patients with chronic or aggressive periodontitis who do not respond favorable to conventional mechanical therapy. The major limitation of all microbiological tests is that the information obtained is relevant to the site sampled, and may not be representative of the microflora of the entire dentition. However, since it is often only specific sites that do not respond to initial therapy, knowing the constituents of the microflora that populate these sites is clinically relevant.

Prevalence of periodontopathic bacteria in aggressive periodontitis patients in a Japanese population

BACKGROUND

Actinobacillus actinomycetemcomitans is considered a major etiologic agent of aggressive periodontitis. Other periodontopathic bacteria such as Porphyromonas gingivalis are also suspected of participating in aggressive periodontitis, although the evidence is controversial. The aim of the present study was to investigate the prevalence of periodontopathic bacteria and to clarify the microbiological features of aggressive periodontitis in Japanese patients.

METHODS

Subgingival plaque was collected from 50 aggressive periodontitis (AgP) patients (localized 10, generalized 40). Samples from 35 generalized chronic periodontitis (CP) patients and 18 healthy subjects were examined as controls. Plaque samples were examined using culture and polymerase chain reaction (PCR) method.

RESULTS

The prevalence of A. actinomycetemcomitans was relatively low in the localized (20%) and generalized (17.5%) AgP patients, with no significant difference observed in detection frequencies between AgP and the control groups (CP 8.6%, healthy 0%). On the other hand, Tannerella forsythensis (formerly Bacteroides forsythus), Campylobacter rectus, P. gingivalis, and Treponema denticola were frequently detected in localized as well as generalized aggressive periodontitis patients. The prevalence and proportion of P. gingivalis correlated with severity of clinical attachment loss in both localized and generalized aggressive periodontitis.

CONCLUSIONS

T. forsythensis, C. rectus, P. gingivalis, and T. denticola were the predominant periodontopathic bacteria of aggressive periodontitis patients in Japan. Although A. actinomycetem- comitans was also detected in AgP patients, the prevalence of this bacterium was much lower than that of P. gingivalis.

Efficacy of a Fluoridated Hydrogen Peroxide-Based Mouthrinse for the Treatment of Gingivitis: A Randomized Clinical Trial

BACKGROUND

A randomized clinical trial was performed to test the efficacy of a fluoridated hydrogen peroxide-based mouthrinse on gingivitis and tooth whitening in a two-phase study. The first phase (28 days) included the experimental gingivitis phase; the second phase (5 months) was the oral hygiene phase, which included rinsing.

METHODS

A total of 99 subjects were included in the study and were randomly assigned to receive either placebo or test mouthrinse. Clinical measures were chosen to reflect the gingival health and tooth whiteness in an intent-to-treat study design. Statistical analyses of clinical parameters related to gingival health and tooth color were conducted, using the method of generalized estimating equations (GEE), with an exchangeable working correlation to accommodate tooth-level data. Baseline differences between the groups were adjusted. Microbial samples taken at the beginning and at the end of the study were analyzed by DNA-DNA hybridization technique, to determine whether there was any adverse shift in supragingival flora.

RESULTS

Eastman bleeding index, modified gingival index, intensity of stain, and extent of stain were significantly reduced in the test group at 6 months compared to baseline (P < 0.05). In contrast, only the Eastman bleeding index was significantly reduced in the control group (P < 0.05). The reduction in the index of gingival inflammation for the test group was significantly greater than for the control group (P = 0.004). Subjects using the test rinse were also six times more likely to exhibit an improvement in tooth color after 6 months than were subjects using placebo (P = 0.002). As a result of the clinical evaluations and microbial analysis, test mouthrinse was found to be safe during a 6-month period.

CONCLUSION

The results of this study indicate that the fluoridated hydrogen peroxide-based mouthrinse effectively whitens teeth and significantly reduces gingivitis.

Occurrence of periodontal bacteria in healthy children: a 2-year longitudinal study

OBJECTIVES

To examine the occurrence of specific periodontal bacteria in children and adolescents.

METHODS

Ten putative periodontal bacteria were longitudinally examined in plaque and saliva samples from 119 periodontally healthy children (2-15 years old) using a polymerase chain reaction method.

RESULTS

Capnocytophaga ochracea, C. sputigena, and Actinobacillus actinomycetemcomitans were frequently found in saliva, and tended to persist in saliva for the remainder of the study, whereas Porphyromonas gingivalis, Treponema denticola, and Prevotella intermedia were rarely detected. P. nigrescens was more frequently detected in plaque and its prevalence increased with age. Eikenella corrodens and Campylobacter rectus were sometimes detected in both plaque and saliva, while Tannerella forsythensis was occasionally detected in saliva.

CONCLUSION

A. actinomycetemcomitans, C. ochracea, C. sputigena, P. nigrescens, C. rectus, and E. corrodens are common members of the oral microbial flora of healthy children, whereas P. gingivalis, P. intermedia, and T. denticola appear to be transient organisms.

Locally delivered antimicrobials for the treatment of chronic periodontitis

The basic treatment of chronic periodontitis is a mechanical debridement of periodontal pockets by scaling and root planing (S/RP) in combination with efficient plaque control. Locally delivered antiseptics (LDA) have been proposed to practitioners and, while subgingival irrigation of antiseptics is still used in clinical practice, the introduction in our therapy of a slow release and sub-gingival delivery of tetracycline has changed the rationale from a mechanical treatment towards a combined therapy for full mouth/sites disinfection. Various antibiotics, antiseptics and resorbable carriers are now proposed with similar targets to arrest disease progression. In chronic periodontitis, LDA cannot be used routinely in combination with S/RP, because of the limited clinical benefit, even if an increased percentage of deep sites may show an improvement. Prospective multicenter studies considering risk factors for disease progression have to be designed to identify patients who may benefit the most from LDA. For non-responding sites or recurrent pockets, the controversies are limited, because a combined S/RP and LDA may avoid the need for surgery. However, the patient cost/benefit ratio needs to be estimated as well as adverse effects in particular antibiotics.

Salivary cystatin activity and cystatin C in experimental gingivitis in non-smokers

BACKGROUND

Subjects with natural gingivitis and periodontitis have elevated levels of salivary cystatins compared to periodontally healthy individuals. Experimental gingivitis studies, however, have yielded conflicting results.

AIM

The present study investigated whether experimentally induced gingivitis is associated with changes in salivary cystatin levels.

MATERIAL & METHODS

Plaque scores, bleeding indexes and whole saliva samples of 35 non-smoking young adults were collected at the start and at the end of an experimental gingivitis trial, and 3 weeks after resuming oral hygiene. The saliva samples were assayed for protein concentrations, cystatin activity and cystatin C concentration.

RESULTS

During experimental gingivitis, plaque and bleeding scores increased significantly in all subjects and subsequently decreased significantly after reinstalment of oral hygiene procedures. No significant changes were observed for the protein concentration, cystatin activity and cystatin C concentration. No significant relation could be established between these salivary parameters and bleeding on marginal probing.

CONCLUSION

The present study confirms earlier results from Lie et al. (2001) that no significant changes occur in salivary cystatin activity and cystatin C concentration during and after experimental gingivitis.

Differences in mouse strain influence leukocyte and immunoglobulin phenotype response to Porphyromonas gingivalis

This study examined the nature of the infiltrating cells in Porphyromonas gingivalis-induced lesions and immunoglobulins in the serum samples of BALB/c (H-2d), C57BL6 (H-2b), DBA/2J (H-2d) and CBA/CaH (H-2k) mice. Mice were immunized intraperitoneally with P. gingivalis outer membrane antigens or sham-immunized with phosphate-buffered saline followed by subcutaneous challenge with live organisms 1 week after the final immunization. The resulting skin abscesses were excised 7 days later, cryostat sections cut and an immunoperoxidase method used to detect the presence of CD4+ and CD8+ T-cell subsets, CD14+ macrophages and CD19+ B cells. Peroxidase positive neutrophils and IgG1- and IgG2a-producing plasma cells were also identified. Anti P. gingivalis IgG1 and IgG2a subclass antibodies were determined in serum obtained by cardiac puncture. Very few CD8+ T cells and CD19+ B cells were found in any of the lesions. The percentages of CD4+ cells, CD14+ cells and neutrophils were similar in lesions of immunized BALB/c and C57BL6 mice, with a trend towards a higher percentage of CD14+ cells in sham-immunized mice. The percentage of CD14+ cells was higher than that of CD4+ cells in immunized compared with sham-immunized DBA/2J mice. The percentages of CD4+ and CD14+ cells predominated in immunized CBA/CaH mice and CD4+ cells in sham-immunized CBA/CaH mice. The percentage of neutrophils in immunized CBA/CaH mice was significantly lower than that of CD14+ cells and CD4+ cells in sham-immunized mice. IgG1+ plasma cells were more dominant than IgG2a+ cells in immunized BALB/c, C57BL6 and DBA/2J mice, whereas IgG2a+ plasma cells were more obvious in sham-immunized mice. IgG2a+ plasma cells were predominant in immunized and sham-immunized CBA/CaH mice. In the serum, specific anti-P. gingivalis IgG2a antibody levels (Th1 response) were higher than IgG1 levels (Th2 response) in sham-immunized CBA/CaH and DBA/2J mice. In immunized BALB/c mice, IgG2a levels were lower than IgG1 levels, while IgG2a levels were higher in immunized C57BL6 mice. In conclusion, this study has shown differences in the proportion of infiltrating leukocytes and in the subclasses of immunoglobulin produced locally and systemically in response to P. gingivalis in different strains of mice, suggesting a degree of genetic control over the response to P. gingivalis.

Sequence analysis of kgp in Porphyromonas gingivalis isolates from periodontitis patients

The aim of the present study was to determine sequence variation in the Lys-x-specific protease (Kgp) encoding gene kgp of Porphyromonas gingivalis and to analyze its association with periodontal disease severity. Pooled subgingival plaque samples were obtained from the six most severely affected sites of 102 patients with periodontitis. Sequence analysis of the kgp gene in 23 clinical P. gingivalis isolates resulted in the identification of two distinct kgp types (kgp-I and kgp-II) according to sequence differences in the region encoding the catalytic domain. Restriction analysis revealed that 59 of the 102 patients were colonized by kgp-I and 43 by kgp-II. Patients harboring kgp-I or kgp-II showed no significant difference in the severity of periodontal disease as assessed by pocket probing depth and bleeding on probing following adjustment for smoking habit and age. Moreover, no differences in proteolytic activity of Kgp-I and Kgp-II were detected. The results indicated that two kgp types are maintained in natural populations of P. gingivalis.

Prevalence of Porphyromonas gingivalis fimA genotypes in Caucasians

The aim of the present study was to determine the prevalence of Porphyromonas gingivalis fimA genotypes in Caucasian patients with periodontitis. A total of 102 patients harboring P. gingivalis subgingivally were enrolled into the study. Pooled subgingival plaque samples of the six most severely affected sites were taken and analysed by fimA-specific polymerase chain reaction (PCR) and restriction analysis. Moreover, 26 P. gingivalis isolates were analysed by sequence analysis of the fimA gene. Sequence analysis revealed five major fimA genotypes (fimA types I-V) and allowed further subtyping of fimA genotypes II and IV into two subgroups each. The overall prevalences of fimA genotypes as assessed by PCR and restriction analysis among the P. gingivalis-positive patients with periodontitis were: type I, 25.5%; type II, 38.2%; type III, 4.9%; type IV, 18.6%; type V, 3.9%; and non-typable, 6.9%. Two patients were colonized by both type II and type IV, or type III and type IV fimA genotypes, respectively. Patients harboring different fimA genotypes showed no significant difference in severity of periodontal disease, as assessed by pocket probing depth and bleeding on probing following adjustment for smoking habit and age. The results indicate that predominant fimA genotypes in Caucasian periodontitis patients are types I, II, and IV. However, there was no difference in the association of the various fimA genotypes with disease severity.

Antibacterial activity of medicinal plant extracts against periodontopathic bacteria

This study was performed to evaluate the antibacterial activity of Althaea officinalis L. roots, Arnica montana L. flowers, Calendula officinalis L. flowers, Hamamelis virginiana L. leaves, Illicium verum Hook. fruits and Melissa officinalis L. leaves, against anaerobic and facultative aerobic periodontal bacteria: Porphyromonas gingivalis, Prevotella spp., Fusobacterium nucleatum, Capnocytophaga gingivalis, Veilonella parvula, Eikenella corrodens, Peptostreptococcus micros and Actinomyces odontolyticus. The methanol extracts of H. virginiana and A. montana and, to a lesser extent, A. officinalis were shown to possess an inhibiting activity (MIC < or = 2048 mg/L) against many of the species tested. In comparison, M. officinalis and C. officinalis extracts had a lower inhibiting activity (MIC > or = 2048 mg/L) against all the tested species with the exception of Prevotella sp. Illicium verum methanol extract was not very active though it had a particular good activity against E. corrodens. The results suggest the use of the alcohol extracts of H. virginiana, A. montana and A. officinalis for topical medications in periodontal prophylactics.

IKK beta plays an essential role in the phosphorylation of RelA/p65 on serine 536 induced by lipopolysaccharide

Activation of the I kappa B kinase (IKK) complex by LPS induces phosphorylation and degradation of I kappa B alpha, leading to the nuclear translocation of NF-kappa B. Although it is essential for NF-kappa B activation, emerging evidence has indicated that the nuclear translocation of NF-kappa B is not sufficient to activate NF-kappa B-dependent transcription. Here, we reported that LPS induced the phosphorylation of the p65 trans-activation domain on serine 536 in monocytes/macrophages. Using mouse embryonic fibroblasts lacking either IKK alpha or IKK beta, we found that IKK beta played an essential role in LPS-induced p65 phosphorylation on serine 536, while IKK alpha was partially required for the p65 phosphorylation. The LPS-induced p65 phosphorylation on serine 536 was independent of the phosphatidylinositol 3'-kinase/Akt signaling pathway. Furthermore, we found that the phosphorylation on serine 536 increased the p65 transcription activity. In summary, our results demonstrate that IKK beta plays an essential role in the LPS-induced p65 phosphorylation on serine 536, which may represent a mechanism to regulate the NF-kappa B transcription activity by LPS.

Humoral immune responses to S-layer-like proteins of Bacteroides forsythus

Bacteroides forsythus is one of the important periodontopathic bacteria, and this microorganism is known to have an S-layer outside the outer membrane. The S-layer-like antigens were recently isolated from B. forsythus, and they were found to be 270- and 230-kDa proteins in the envelope fraction. In this study, these proteins were confirmed to be specific to B. forsythus by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and they were clearly recognized by sera from patients with adult and early-onset periodontitis in Western immmunoblot analysis. We compared the immunoglobulin G (IgG) responses against the purified S-layer-like antigen by enzyme-linked immunosorbent assay. IgG responses against this antigen were low in healthy control subjects, but they were significantly higher in subjects with adult and early-onset periodontitis. Together with the fact that the IgG responses against the crude extract of B. forsythus did not rise significantly in patients with periodontitis, S-layer-like proteins are considered to be specific antigens of B. forsythus and may play an important role in the progression of periodontitis.

Accidentally induced periodontitis in primary dentition: longitudinal examinations of periodontal bacteria and clinical conditions

Periodontitis is very rare in the primary dentition although it can be accidentally induced in young children. The purpose of this study was to describe a case of periodontitis in a 4-year-old child, which was accidentally induced by insertion of small plastic tubes into the dental cervix of the primary incisors during play, and to discuss the clinical, radiographic, and microbiological findings. Removal of the plastic tubes resulted in resolution of the periodontal condition. Prevotella nigrescens and Campylobacter rectus were detected in subgingival plaque samples from the affected teeth at every examination, whereas Porphyromonas gingivalis, Treponema denticola, Prevotella intermedia, and Bacteroides forsythus were never found during the two-year observation period. The clinical and microbiological results suggest that the type of periodontitis caused by such an incidence is not progressive, unlike other periodontal diseases such as prepubertal and juvenile periodontitis.

Are dental diseases examples of ecological catastrophes?

Dental diseases are among the most prevalent and costly diseases affecting industrialized societies, and yet are highly preventable. The microflora of dental plaque biofilms from diseased sites is distinct from that found in health, although the putative pathogens can often be detected in low numbers at normal sites. In dental caries, there is a shift towards community dominance by acidogenic and acid-tolerant Gram-positive bacteria (e.g. mutans streptococci and lactobacilli) at the expense of the acid-sensitive species associated with sound enamel. In contrast, the numbers and proportions of obligately anaerobic bacteria, including Gram-negative proteolytic species, increase in periodontal diseases. Modelling studies using defined consortia of oral bacteria grown in planktonic and biofilm systems have been undertaken to identify environmental factors responsible for driving these deleterious shifts in the plaque microflora. Repeated conditions of low pH (rather than sugar availability per se) selected for mutans streptococci and lactobacilli, while the introduction of novel host proteins and glycoproteins (as occurs during the inflammatory response to plaque), and the concomitant rise in local pH, enriched for Gram-negative anaerobic and asaccharolytic species. These studies emphasized (a). significant properties of dental plaque as both a biofilm and a microbial community, and (b). the dynamic relationship existing between the environment and the composition of the oral microflora. This research resulted in a novel hypothesis (the 'ecological plaque hypothesis') to better describe the relationship between plaque bacteria and the host in health and disease. Implicit in this hypothesis is the concept that disease can be prevented not only by directly inhibiting the putative pathogens, but also by interfering with the environmental factors driving the selection and enrichment of these bacteria. Thus, a more holistic approach can be taken in disease control and management strategies.