Periodontology 2000, Vol.
53, 2010, 70–88
Printed in Singapore. All rights reserved
Comparison of the
microbiological features of
chronic and aggressive
periodontitis
G A R Y C. A R M I T A G E
Any discussion of the comparative microbiology of
chronic and aggressive forms of periodontitis must
begin with the premise that our knowledge of the
microbiota associated with these infections is
incomplete. This does not mean that the field of oral
microbiology has neglected the study of periodontal
infections. On the contrary, the microbiota associ-
ated with periodontal health and disease has been
intensely studied for well over a century by several
generations of skilled scientists and clinicians (9, 15,
23, 42, 47, 48, 60, 65, 82, 101, 102, 105, 113, 114, 122,
123, 135, 145, 147, 149, 171, 175, 177, 181, 184, 206).
The basic problem is that the oral microbiota is an
enormously complex and dynamic entity that is
profoundly affected by perpetually changing local
environments and host-mediated selective pressures.
In addition, the microorganisms live in hard-to-study
biofilms comprising organized polymicrobial com-
munities that are elegantly adapted to thriving and
surviving in the multiple micro-ecosystems of the
oral cavity.
Another complication in any discussion of peri-
odontal microbiology is the educational bias regard-
ing the nature of infectious diseases that healthcare
professionals develop during their training. Most
dentists and physicians were taught the classical
features of infectious diseases in their basic courses
in medical microbiology. The dominant paradigm
taught in these courses is that an exogenous patho-
gen overcomes the innate and adaptive immune
defenses of the host, replicates within the body, and
causes disease through a variety of virulence factors.
Diagnosis of these classical infections often involves
submitting a clinical specimen obtained from the
70
 2010 John Wiley & Sons A/S
PERIODONTOLOGY 2000
infected patient to a clinical laboratory for isolation
and identification of the pathogen by growing it in
pure culture on artificial medium. These cultures are
then used to determine the sensitivity of the isolated
pathogen to a panel of antibiotics. Treatment of the
infection involves administration of an appropriate
regimen of antibiotics that is intended to suppress or
eliminate the pathogen. This model for infectious
diseases is certainly not the only one that is taught at
most medical or dental schools, as it is widely known
that some infections can be caused by multiple
bacteria (i.e. ÔmixedÕ infections) and some diseases
can be due to commensal opportunistic pathogens
(82). Nevertheless, the one pathogen ⁄ one disease
model dominates the thinking of most physicians
and many dentists.
Unfortunately, this dominant paradigm does not
apply in cases of periodontal infections. These
infections are caused by an extremely diverse con-
sortium of microorganisms that are part of the
endogenous microbiota of most people (82, 157).
Many individuals who are periodontally healthy carry
or harbor some periodontal pathogens as part of their
normal supragingival and subgingival microbiota (4,
26, 32, 35, 43, 61, 62, 77, 94, 119, 129, 143, 150, 153,
155, 179, 180, 189, 196, 200, 203, 207). When detect-
able at healthy sites, the pathogens are usually pres-
ent in very low numbers and show a limited range of
phylotypes. It is quite clear that many individuals can
harbor potential pathogens for long periods of time
without developing periodontal disease. Carriage of
putative periodontal pathogens at low levels as part
of the commensal or normal oral microbiota is
probably beneficial, since it is likely that their

presence is necessary for the development and mat-
uration of innate and adaptive immunity of the host
(27, 33, 170, 185).
The microbiological picture of chronic and
aggressive periodontitis is further complicated by
the fact that only about 50–60% of the subgingival
microbiota can be grown in the laboratory using
state-of-the-art culturing techniques. The remainder
of the microbiota is in a Ônot-yet-cultivatedÕ category
(45, 158, 197). This is problematic, as it would be
astonishing if periodontal pathogens were only
confined to the portion of the subgingival microbiota
that can be grown on artificial media in the
laboratory. This problem is not unique to oral
microbiology, as environmental microbiologists have
known for a long time that the vast majority of the
microorganisms on the planet cannot be grown using
currently available culturing technologies. Ecologists
refer to this phenomenon as the Ôgreat plate
anomalyÕ, whereby microscopic and plate counts of
microorganisms from certain aquatic environments
are dramatically different (178). In such cases,
microscopic estimates of the number of viable cells
using vital-staining dyes such as acridine orange are
often much higher than colony counts on culture
plates (178). Any attempt to compare the microbio-
logical features of chronic and aggressive periodon-
titis must take into account the existing fragmentary
knowledge of the composition of the oral microbiota.
Another major impediment to understanding the
nature of periodontal infections is that the pathogens
do not act alone but are part of complex microbial
communities called biofilms (46, 96). Biofilms are
populations of microorganisms that are concentrated
on a surface and surrounded by an extracellular slime
matrix of microbial origin known as the glycocalyx.
It is well established that the biochemical and
metabolic properties of free-floating or planktonic
microorganisms are quite different when these same
microbes become part of an adherent biofilm com-
munity (109, 176, 177). For example, some bacteria
appear to sense when they touch a solid surface.
Contact with the surface triggers activation of genes
that facilitate irreversible attachment of the bacteria
to the solid surface (151). In addition, other genes are
up-regulated that enhance survival as part of a
biofilm community in which numerous microbe–
microbe interactions occur (83, 84, 116, 134, 202). For
example, it has been estimated that, when Por-
phyromonas gingivalis is grown as an in vitro biofilm,
approximately 18% (377 genes) of its genome is
differentially expressed compared to when it is grown
under planktonic conditions (134). On the other
Microbiology of chronic and aggressive periodontitis
hand, the percentage of differential gene expression
under planktonic vs. biofilm conditions for Pseudo-
monas aeruginosa is only approximately 1% (73
genes), suggesting wide variations among bacteria
with regard to this parameter (194). From an etio-
logical perspective, it is important to note that genes
for certain virulence factors are up-regulated in some
bacteria once they become members of a biofilm
(162). An important feature of microbial communi-
ties in biofilms is increased synthesis of quorum-
sensing molecules that promote coordinated
reactions of the entire biofilm to external stimuli (14,
144, 169). Indeed, biofilms tend to behave like
multicellular organisms when challenged with
significant environmental changes (17, 144). Finally,
horizontal gene transfer between similar and
dissimilar microorganisms promotes the preservation
of genes that enhance survival in highly organized
and competitive biofilm ecosystems (107, 159, 160,
186, 193, 195). The important point is that the
biochemical and physiological properties of estab-
lished periodontal pathogens are modified once the
microorganism becomes part of a biofilm. The
disease-producing abilities of periodontal pathogens
are clearly modified by their interactions with other
members of the biofilm community. In some
instances, their virulence is enhanced (21, 107, 130),
whereas in other cases it is inhibited (199) by the
influence of neighboring microorganisms within the
biofilm. Although only a few dozen types of micro-
organisms have been strongly implicated as etiological
agents for chronic and aggressive forms of perio-
dontitis (175–177), they do not act independently of
their neighbors. In this sense, all periodontal
infections have a diverse polymicrobial etiology.
The final, and perhaps most perplexing, impedi-
ments to comparing the microbiology of various
forms of periodontitis are: (i) the inability to deter-
mine when these infections are progressing or not
progressing (active vs. inactive disease), and (ii)
inconsistent and variable case definitions for the
diseases. The progression of periodontitis tends to be
episodic (i.e. additional attachment loss occurs in
bursts interspersed between periods of quiescence)
(63), and it is currently impossible to determine when
these events are taking place (2, 3, 16, 136). The
composition of a subgingival biofilm at a site that is
in remission should be characteristic of the micro-
biota associated with host–microbe homeostasis. It is
likely that a quite different microbiota will be recov-
ered from a progressing site where there is significant
disruption in the biofilm–tissue homeostasis. Finally,
inconsistent and multiple criteria have been used in
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the literature to define cases of chronic versus
generalized aggressive forms of periodontitis (28).
These two problems are probably partly responsible
for some of the wide variations in the reported
composition of the subgingival microbiota in various
forms of periodontitis.
Criteria for determination of a
periodontal pathogen
In an important paper published in 1979, Socransky
(174) pointed out that the 2nd and 3rd KochÕs pos-
tulates cannot be fulfilled in cases of periodontitis.
KochÕs 2nd postulates stipulates that the pathogen
can be grown in the laboratory on artificial media,
and his 3rd postulate requires that inoculation of a
pure culture into experimental animals causes a
condition similar to the human disease from which
the organism was initially isolated. Socransky (174)
suggested five types of criteria or lines of evidence
that can be used to support an etiological role for
certain microorganisms in periodontal infections: (i)
association with disease, (ii) elimination or suppres-
sion of the organism, (iii) host response, (iv) animal
pathogenicity, and (v) mechanisms of pathogenicity.
Application of these criteria to known components of
the periodontal microbiota currently serves as the
primary basis for believing that certain microorgan-
isms are pathogens that cause chronic and aggressive
forms of periodontitis.
Association with disease
This criterion simply states that the putative patho-
gen should be at higher levels (numbers or propor-
tions) at diseased sites than at healthy sites. This does
not mean that the pathogen needs to be a predomi-
nant member of the periodontal microbiota. Indeed,
many suspected cultivable periodontal pathogens
only represent approximately 1–5% of the colony-
forming units at sites with chronic periodontitis
(147). This criterion can also be applied to micro-
organisms that are in the Ônot-yet-cultivatedÕ cate-
gory, with the primary means of detection being
molecular identification of 16S ribosomal RNA gene
sequences and other similar markers (158).
Elimination or suppression of the
organism
This criterion specifies that progression of periodon-
titis is arrested if the putative pathogen is suppressed
72
or eliminated by an appropriate form of periodontal
therapy. One must be cautious when using the word
ÔeliminatedÕ in this context, since there is good
evidence that many periodontally healthy people carry
low levels of periodontal pathogens as part of their
endogenous subgingival microbiota (76, 94, 119, 129,
153, 180, 189, 200). It is highly unlikely that a member
of the normal or resident microbiota will be perma-
nently eliminated from the oral ecosystem, and it can
thus be detected if a highly sensitive molecular method
is used (187). Nevertheless, therapy can certainly
reduce the subgingival levels of suspected periodontal
pathogens (1, 25, 37, 64, 65, 167, 187), and treatment
may reduce the levels of the putative pathogens to
below the limits of detection, at least during the short
follow-up periods of most studies (29, 163).
Host response
This is an important criterion for causation since
most of the periodontal damage associated with the
presence of subgingival biofilms is believed to be
due to host inflammatory responses to this microbial
challenge (55, 56, 168). A heightened cellular and ⁄ or
humoral immune response to a specific inhabitant of
the biofilm might suggest a possible etiological role
for that microorganism (39, 54–56, 183). Alternatively,
a lower than expected host response may indicate a
special ability of the putative pathogen to avoid
immune surveillance mechanisms of the host. In
either case, an aberrant immune response may
represent a disruption in the host–microbiota mutu-
alism necessary for the maintenance of periodontal
health (27, 170).
Animal pathogenicity
Inoculation of a suspected human pathogen into an
experimental animal is an important part of KochÕs
method for establishing an etiological role of a
microorganism (174). For over 50 years, this proce-
dure has also been used to help understand the nature
of a number of oral infections, including dental caries
(50, 59) and periodontal disease (58, 91). Historically
important related studies on caries and periodontitis
in experimental animals convincingly showed that
these diseases were both transmissible via infectious
agents (90, 100, 101). It has been demonstrated that
several putative periodontal pathogens isolated from
human cases of periodontitis can cause similar perio-
dontal lesions when inoculated into experimental
animals (24, 44, 53, 60, 78, 80, 86–89, 92, 104, 133, 138,
173, 182, 198). Such findings, together with positive

results from other types of studies including epide-
miological associations, suppression ⁄ elimination of
specific microbes via treatment, and host response
data, all contribute to the conclusion that a given
microorganism is a probable periodontal pathogen.
However, inoculation of experimental animals
with potential periodontal pathogens is often not
successful (174). For example, fastidious organisms
such as spirochetes cannot be used for monospecies
implantation as they require other bacteria to
create a microenvironment that is suitable for colo-
nization. It is quite likely that many highly virulent
periodontal pathogens are unable to colonize the
mouths of experimental animals. In addition, even
in cases where disease is initiated by introduction
of a human microorganism into the mouth of an
experimental animal, the induced condition is often
clinically different to the human disease from
which the bacterium was originally isolated (174). In
many cases, extensive bone loss occurs in the
absence of any clinically detectable dental plaque
biofilms (60, 78, 87, 88). Finally, in some cases,
implantation of a microorganism such as Strepto-
coccus mutans that is not considered to be a human
periodontal pathogen will cause severe alveolar bone
loss in some experimental animals (59, 103). Never-
theless, the results of animal pathogenicity studies
are useful in conjunction with other lines of evidence
supporting an etiological role in the pathogenesis of
periodontal infections.
The number of studies involving gnotobiotic
animals has increased in the past decade, and such
studies are beginning to shed light on the mecha-
nisms involved in the homeostasis between animal
hosts and potential pathogens residing in the com-
mensal microbiota (27, 33, 170, 185). The presence of
a commensal microbiota, including potential patho-
gens, is essential for the proper development of
mucosal immunity (27, 185). Unlimited immune
activation from constant antigenic stimulation by
components of the commensal microbiota is not
compatible with host–microbe homeostasis or the
mutualism that is required for the maintenance of
health (170, 185). Regulation of potentially harmful
local immune responses associated with the presence
of the commensal microbiota is quite complex and
involves poorly understood interactions between the
innate and adaptive components of the immune
system (27, 33, 148, 170, 185). A better understanding
of these interactions is important since most peri-
odontal infections appear to be caused by disruption
in the homeostasis between the host and commensal
microbiota (82, 106, 124, 140). Successful periodontal
Microbiology of chronic and aggressive periodontitis
therapy involves restoration of the host–microbe
homeostasis associated with health.
Mechanisms of pathogenicity
The last of the Socransky criteria (174) for a peri-
odontal pathogen is that the microorganism should
possess an array of virulence factors that promote its
ability to initiate and perpetuate inflammatory and
immunological events that result in periodontal
damage. Virulence factors include properties of
microorganisms that help them to avoid host
defenses and ⁄ or contribute to the damage and
destruction of host tissues (51). In some respects, this
is the easiest of the Socransky criteria to satisfy as
most microorganisms in the oral microbiota have
co-evolved with their human hosts and are well-
adapted to bypassing innate and adaptive immune
clearance mechanisms of the host. The members of
the subgingival microbiota that flourish when the
periodontal tissues are inflamed are also those that
are best equipped to produce factors that cause
damage. Since these microorganisms are especially
adapted to thrive in inflamed conditions, they are
identified as probable periodontal pathogens. These
microbes damage tissues by inducing inflammatory
and immune responses, and thereby create
conditions that promote their survival in the highly
competitive subgingival ecosystem.
Microorganisms that rank high on the list of
periodontal pathogens have multiple ways in which
they can participate in the etiology of periodontal
infections. For example, P. gingivalis produces a wide
spectrum of proteinases, including some that can
cleave host immunoglobulin molecules that become
attached to the cell surface of the microorganism
(81). It has the ability to enter and replicate within
host cells, thereby making it a true intracellular
pathogen (36). Based on in vitro data, it can spread
from infected epithelial cells to adjacent uninfected
cells (205). It possesses a potent endotoxin (lipo-
polysaccharide) as part of the outer membrane of its
cell wall, and produces many low-molecular-weight
irritants such as ammonia, H2S, volatile sulfur com-
pounds, indole and short-chain fatty acids (81). It is
an abundant source of small outer membrane vesi-
cles or proteoliposomes that facilitate its interaction
with other bacteria (111) and inactivate or suppress
normal host responses (38).
A long list of potential pathogenic mechanisms can
also be generated for Aggregatibacter (Actinobacillus)
actinomycetemcomitans. It adheres tightly to a variety
of host tissues, produces potent bacteriocins that give
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it a competitive edge over other bacteria, and readily
develops resistance to antibiotics such as the tetra-
cyclines (51). It possesses a heat-labile cytolethal
distending toxin that kills fibroblasts (79), and is an
abundant source of a leukotoxin that kills host
neutrophils and macrophages (79, 93). It produces
outer membrane vesicles that provide the organism
with a way to deliver a concentrated or enriched
source of leukotoxin when attacked by host
neutrophils (97). It is interesting that leukotoxic
strains of the microorganism produce more vesicles
than non-leukotoxic strains (118).
The lists of potential pathogenic mechanisms for
P. gingivalis and A. actinomycetemcomitans are quite
long for two fundamental reasons: (i) they actually do
possess these virulence factors, and (ii) these bacteria
are easy to grow and can be studied in detail under a
wide range of experimental conditions. Indeed, these
two periodontal pathogens are the most widely
studied among a growing number of candidate
pathogens. In some respects, the emphasis that has
been placed on these two bacteria in the literature
has drawn attention away from other possible, and
perhaps equally important, pathogens that are not so
easily studied. Although there is no question that
these two pathogens are important in the initiation
and progression of periodontal diseases, it may be
that they are not the most virulent bacteria in the
subgingival microbiota.
Periodontal pathogens circa 1996
At the 1996 World Workshop in Periodontics, leading
research periodontists and oral microbiologists used
an evidence-based approach to arrive at a consensus
list of periodontal pathogens (57). They used the five
Socransky criteria (discussed above) as the primary
basis to generate their list. A 6th criterion, detection
of the microorganism prior to disease progression,
was used as an additional line of evidence for
pathogenicity. It was concluded that there is strong
evidence that P. gingivalis, A. actinomycetemcomi-
tans and Tannerella forsythia (formerly Bacteroides
forsythus) are periodontal pathogens when present in
sufficient numbers in susceptible hosts (57). There
was moderate evidence to support an etiological role
for Campylobacter rectus, Eubacterium nodatum,
Prevotella intermedia ⁄ nigrescens, Parvimonas micra
(formerly Micromonas micros and Peptostreptococcus
micros), the Streptococcus intermedius complex and
Treponema denticola (57). The group also concluded
that there was ÔinitialÕ evidence to include the
74
following microorganisms on the list of probable
periodontal pathogens: Eikenella corrodens, enteric
rods, Pseudomonas species, Selenomonas species and
Staphylococcus species. No detailed attempt was
made to compare the putative pathogens in the var-
ious forms of periodontitis. However, the consensus
report stated that A. actinomycetemcomitans is most
often found in aggressive (Ôearly-onsetÕ) periodontitis,
whereas P. gingivalis and T. forsythia are found more
frequently in chronic (Ôadult-onsetÕ) periodontitis
(57). This report received widespread acceptance by
the periodontal community at the time, and is still
regarded as valid. The periodontal pathogens of 1996
all remain on the list of pathogens in 2010.
Periodontal pathogens circa 2010
Although there were relatively few bacteria on the
1996 list, it should be emphasized that periodontal
diseases are polymicrobial in nature and there is no
evidence that they are monoinfections. The patho-
gens act as part of a bacterial consortium within a
complex and dynamic dental plaque community
(46). In the past decade, there has been an explosion
in our understanding of periodontal microbiology,
and the list of putative periodontal pathogens has
grown considerably. For the most part, the pathogen
list of 1996 was confined to bacteria that could be
grown on artificial media in the laboratory. There-
fore, members of the oral microbiota that are in the
Ônot-yet-cultivatedÕ group (i.e. approximately 50%)
were not included as etiological candidates. Since
1996, there has been widespread application of
culture-independent methods to detect disease-
associated subgingival microorganisms that cannot
yet be grown in the laboratory (9, 19, 20, 31, 34, 45, 67,
85, 99, 108, 112–115, 123, 126–128, 142, 156, 157, 161,
164, 166, 190–192). Based on analysis of 16S rRNA
gene sequences and other molecular markers, the list
of microorganisms that are candidates for periodon-
tal pathogens has become considerably longer
(Table 1). Application of molecular techniques to the
analysis of clinical samples collected from subgingi-
val sites has made it possible to examine a wider
range of the microbial diversity present at such sites.
In addition to the considerable diversity of the
microbial population of subgingival biofilms, it has
become increasingly apparent that there is
extensive diversity within a given microbial species.
For example, not all strains and serotypes of
A. actinomycetemcomitans are equally pathogenic
(35, 47, 49, 66, 74, 98, 102, 160, 204). The JP2 clone of
 Microbiology of chronic and aggressive periodontitis

Table 1. Microorganisms associated with various forms of periodontitis as detected by culture-independent methods
and grouped according to their domain (Bacteria or Archaea) and taxonomic phyla or candidate phylogenetic divisions

References
BACTERIA

Bacteroidetes
Porphyromonas gingivalis 19*, 85, 142, 156, 164
Porphyromonas endodontalis 85, 113, 156
Tannerella forsythia 19*, 126, 156, 164
Tannerella sp. 114
AU126 from the Bacteroidetes phylum 113
Prevotella denticola 113
Prevotella intermedia 164
Prevotella spp. 19*
Bacteroidetes sp. oral taxa 272 ⁄ 274 19*
Sphaerocytophaga sp. oral taxa 337 19*
Spirochaetes
Treponema spp. 19*, 31, 114
Treponema socranskii subsp. buccale 85, 156
Clone Treponema sp. 1:G:T21 156
Treponema lecithinolyticum 164
Synergistetes
OTU 4.2 of the ÔSynergistetes Ôphylum 190
Synergistes sp. cluster II 19*
Desulfovibrio-like sp. (oral strain NY682; identical to 121, 137, 191
Desulfovibrio fairfieldensis)
Other Desulfovibrio-like sp. (uncultured bacteria 191
designated dsrAB-I, dsrAB-II, dsrAB-III, dsrAB-IV)
Proteobacteria
Campylobacter rectus 156
Campylobacter gracilis 19*
Desulfobulbus sp. oral clone R004 156
Desulfobulbus sp. oral taxa 041 19*
Desulfobulbus sp. 114
Eikenella corrodens 19*
Brevundimonas diminuta 19*
Actinobacteria
Atopobium rimae  156
 
Atopobium parvulum 156
Cryptobacterium curtum  113
Firmicutes
Streptococcus constellatus  85, 156

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Table 1. Continued

References
 
Gemella haemolysans 156
 
Catonella morbi 85
Granulicatella adiacens  19*, 85, 156
Dialister pneumosintes 20, 34, 85
Dialister invisus ⁄ pneumosintes 19*
 
Peptostreptococcus sp. 114
 
Parvimonas micra 19*
Filifactor alocis  19*, 85, 115, 156
 
Filifactor sp. 114
Uncultured Eubacterium PUS9.170* 67, 156
 
Eubacterium saphenum 85, 113, 156
Eubacterium nodatum  19*
 
Eubacterium sp. 114
 
Mogibacterium timidum 19*, 142
 
Pseudoramibacter alactolyticus 19*
 
Solobacterium moorei 19*
Selenomonas sp. 114
Selenomonas sputigena 45
Selenomonas noxia 19*, 45
Selenomonas sp. EW084 45
Selenomonas sp. EW076 45
Selenomonas sp. FT050 45
Selenomonas sp. P2PA_80 45
Selenomonas sp. GAA14 45, 85
 
Shuttleworthia satelles 19*
Mycoplasma salivarium 19*
Veillonella atypica 19*
Acidaminococcaceae (G-1) (oral taxa 132/150/1155/148/ 19*
135)
Fusobacteria
Fusobacterium animalis 156
Deferribacteres
Deferribacteres DO84 clone 113, 156
Deferribacteres clone BH017 113
Deferribacteres sp. 114
TM7 (candidate phylogenetic division)
I025 TM7 phylotype  9, 113, 152
TM7 spp. oral taxa 346 ⁄ 356 19*

76

Table 1. Continued
Obsidian pool (OP11) (candidate phylogenetic division)
Megasphaera clone BB166
Megasphaera clone X112
Megasphaera sp.
Phylum not established
Acetogenic uncultured bacteria (designated fhs-I,
fhs-II, fhs-III)
ARCHAEA
Euryarcheota
Methanobrevibacter oralis
Methanobrevibacter oralis-like (uncultured microbes
mcrA-1 and mcrAII)
Methanobrevibacter smithii
Methanobrevibacter sp.
Methanobrevibacter sp. SBGA-2
Note: There were wide variations from paper to paper in the clinical criteria used to define cases of ÔperiodontitisÕ. Therefore, no distinction is made in this Table
between chronic, generalized aggressive and refractory forms of periodontitis.
Gram-positive bacteria.
*The population studied by Colombo et al. (19) included patients who were refractory or did not respond to conventional periodontal therapy.
In the data from Paster et al. (156), pathogens were defined as the presence of the microorganism in at least 4 ⁄ 22 (18%) of the subjects with periodontitis (i.e.
n = 9 chronic periodontitis, n = 11 refractory periodontitis, n = 2 HIV-positive individuals with periodontitis) and absent in all of the periodontally healthy subjects
(n = 5).
Faveri et al. (45) used criteria for clinical cases of generalized aggressive periodontitis consistent with those cited in the 1999 classification system (120).
A. actinomycetemcomitans (serotype b) has a 530 base
pair deletion in its leukotoxin reporter gene operon
that enhances its production of leukotoxin by 10–20-
fold compared to non-leukotoxic strains (10, 76).
Similarly, there is extensive diversity in the patho-
genic potential of the many strains and clones of
P. gingivalis (102, 165). The important point is that
not all strains or clones of a given putative pathogen
are equally effective as etiological agents. Therefore,
for maximum clinical utility, microbiological moni-
toring of periodontal pathogens should include anal-
ysis of specific pathogenic strains or clones rather
than all variants of a given species. Some of the re-
ported problems with microbial testing of the sub-
gingival microbiota for diagnostic and treatment
outcome purposes may relate to significant variations
in the pathogenicity of putative periodontal patho-
gens (164).
An interesting finding that has emerged from these
culture-independent studies is the association of
microorganisms from the Archaea domain with
periodontal disease (112, 122, 123, 127, 128, 191, 192,
201). Archaea are prokaryotes that physically resem-
ble bacteria but have different nucleotide sequences
Microbiology of chronic and aggressive periodontitis
References
85, 113
113
114
191
112, 123, 128, 192, 201
191
6, 112
112
123
in their 16S rRNA genes and are therefore not in the
Bacteria domain. Indeed, they are genetically closer
to microbes in the Eukarya domain than those
belonging to the Bacteria domain (7, 11, 68). Their
association with periodontitis is quite striking as they
appear in progressively greater numbers in the sub-
gingival microbiota as a function of disease severity
(i.e. probing depth and clinical attachment loss) (123,
201). Of the three domains of microbial life (i.e.
Eukarya, Archaea and Bacteria), Archaea is the only
group in which pathogens have not yet been dem-
onstrated (40). However, it is theoretically possible,
even likely, that some members of this domain will
eventually be shown to be pathogenic (15, 40).
Fig. 1 shows the clinical and radiographic
appearance of a medically healthy, non-smoking,
30-year-old white male with severe periodontitis who
harbored Methanobrevibacter oralis at each of the
seven subgingival sites that were sampled. This
methane-producing microorganism is the most
commonly found archaean associated with perio-
dontal disease. Although a cause-and-effect rela-
tionship has not been shown, Archaea have never
been found in the subgingival microbiota of perio-
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Fig. 1. Clinical (A) and radiographic (B) appearance of a
30-year-old white male with severe periodontal destruc-
tion. The patient was a medically healthy non-smoker
who had never had any form of periodontal therapy.
Subgingival plaque samples were collected from seven
dontally healthy individuals (123, 127, 128, 201) or at
healthy sites in patients with periodontitis (123). The
percentage of chronic periodontitis patients who
harbor Archaea at subgingival sites ranges from
approximately 19–73% depending on the population
surveyed (123, 128, 191, 201). It has been reported
that non-surgical treatment of Archaea-positive
chronic periodontitis sites was able to reduce these
microorganisms to non-detectable levels at post-
treatment visits (123).
Although M. oralis has been cultured in the labo-
ratory (6, 12), it is difficult to grow and is not isolated
during routine microbiological assessments. Since
strong periodontitis association data are now avail-
able, attempts should be made to examine potential
pathogenic mechanisms of this group of microor-
ganisms. It has been shown that M. oralis antigens
78
non-adjacent subgingival sites with probing depths
‡6 mm and analyzed for 16S rRNA gene sequences. All
seven sites were positive for Methanobrevibacter oralis, a
member of the Archaea domain.
induce the production of specific IgG antibody by
periodontitis patients who harbor the microorganism
as part of their subgingival microbiota (201). There is
some evidence that subgingival methanogens out-
compete sulfate-reducing bacteria and acetogenic
bacteria for available H2 in the local environment
(191). These three groups of hydrogenotrophic
microorganisms play an important role in the overall
subgingival ecology by regulating the levels of H2,
and thereby affecting the levels of secondary fer-
menting periodontal pathogens (191). Other investi-
gators have reported that subgingival sites of chronic
periodontitis patients with high levels of methano-
genic Archaea have low levels of Treponema spp.
(123). The converse is also true, i.e. if there are high
levels of Treponema spp., there are few or no Archaea
(123). Finally, it is possible that methanogenic

Archaea have no direct pathogenic effects but con-
tribute to the overall pathogenicity of subgingival
biofilms by syntrophic interactions with other
microbes (21, 191). Such interactions are those that
promote or otherwise affect the pathogenicity of
neighboring microbes.
Since many of the microorganisms shown in Table 1
cannot yet be cultured, it is only possible to apply the
first two of SocranskyÕs criteria for pathogenicity (i.e.
association with disease and elimination or suppres-
sion of the organism). An important periodontal
pathogen such as P. gingivalis is relatively easy to
grow and study, and therefore there are thousands of
research papers on this bacterium. Indeed, if one
enters the name of this organism in the PubMed
search engine, a list of over 4000 citations is generated.
If this is done for A. actinomycetemcomitans, over
2800 papers are cited. However, simply because
certain microorganisms are easy to study does not
mean that they are the most important periodontal
pathogens in the subgingival microbiota. Neverthe-
less, there should be no doubt that, under the right
circumstances, P. gingivalis and A. actinomycetem-
comitans are important pathogens in some subgingi-
val biofilms. Based on the emerging picture of a very
diverse group of putative periodontal pathogens in the
subgingival microbiota (Table 1), it is a mistake to
oversimplify the situation and confine the list of
pathogens to that published in 1996 (57). Indeed, it
can be seen from Table 1 that the list of putative
pathogens is not limited to gram-negative anaerobic
bacteria. It is clear that a large number of gram-posi-
tive bacteria are also putative periodontal pathogens.
In some instances, the association of a group of
microorganisms with chronic periodontitis may be
strong in early stages of the disease, but may be less
important in advanced cases of the disease. For
example, Brinig et al. (9) found a statistically signifi-
cant association between levels of TM7 bacteria at
subgingival sites with slight periodontal damage (i.e.
clinical attachment loss of 2–3 mm), but the associa-
tion was less pronounced at sites with severe damage
(i.e. clinical attachment loss ‡6 mm). This was espe-
cially true for the I025 clone of TM7. Bacteria in the
TM7 division are gram-positive, and none have yet
been cultured in the laboratory. As is the case with
most uncultivable microorganisms, viable isolates are
not available for evaluating their potential pathogenic
mechanisms either in vitro or in vivo. However, in
addition to the association of TM7 bacteria with
periodontal disease (9, 113, 152, 156), this group of
bacteria has recently been associated with active
inflammatory bowel disease (110). Culture-indepen-
Microbiology of chronic and aggressive periodontitis
dent microbial analyses of colonic biopsies from
patients with active ulcerative colitis revealed the
presence of the same I025 clone that has been asso-
ciated with chronic periodontitis. This TM7 clone was
not found in control biopsies taken from various
segments of the colon during routine colonoscopies in
healthy subjects without inflammatory bowel disease
(110).
Combined genomic and proteomic analyses of
host–biofilm interactions are beginning to reveal the
complex gene–protein interconnected networks
present in periodontal health and disease (139). The
concept is emerging that different bacteria appear to
be associated with clinically similar periodontal dis-
eases in different people, and the oral microbiota
associated with disease progression may be person-
specific (46). The notion that the resident microbiota
in a given body habitat is person-specific is sup-
ported by analysis of molecular data from the human
intestinal tract (41, 141, 188). It has been found that
the microbial profiles of fecal samples collected at
various times from a given individual are more
similar to each other than to the intestinal microbial
communities in a different individual (30, 41, 141,
188). The person-specific characteristics of the
intestinal microbiota are most marked at the species
and strain levels (30, 41, 125, 141).
Comparative microbiology of
chronic vs. generalized aggressive
periodontitis
Comparison of the subgingival microbial profiles in
chronic vs. generalized aggressive periodontitis has
been complicated by the different case definitions
and variable study designs ⁄ methods used by differ-
ent investigators (28, 154). Despite these problems, it
has been possible to make some general comparisons
of the subgingival microbial profiles associated with
chronic and aggressive forms of periodontitis.
Mombelli et al. (146) performed a systematic review
in an attempt to answer the following focused
question ÔCan the presence or absence of periodontal
pathogens (i.e. P. gingivalis, A. actinomycetemcomi-
tans, P. intermedia, T. forsythia and Campylobacter
rectus) distinguish between subjects with chronic and
aggressive periodontitis?Õ. The overall answer to this
question was ÔNoÕ (146). However, in most of the
papers included in the systematic review, the diag-
nostic criteria used to place patients in the various
disease categories were not clearly specified. In the
79
Armitage
final analysis of the systematic review data, no dis-
tinction was made between localized and generalized
forms of aggressive periodontitis. It was found that a
diagnosis of aggressive periodontitis was more often
given in patients positive for A. actinomycetemcomi-
tans, but there were many individuals with aggressive
periodontitis who did not harbor this organism (146).
There are only a few studies that have directly
compared the composition of the subgingival
microbiota in generalized aggressive periodontitis vs.
that in chronic periodontitis (45, 52, 117, 164). In a
population of Chilean patients with chronic perio-
dontitis (n = 17) or generalized aggressive periodon-
titis (n = 6), culture analysis was used to compare the
composition of the subgingival microbiota between
the two diseases. On the bases of isolation frequen-
cies and mean percentage of total counts, a strong
association with P. gingivalis was found for both
chronic periodontitis and generalized aggressive
periodontitis. However, this microorganism was only
isolated from 13 ⁄ 17 (76.5%) of the chronic
periodontitis patients compared with 6 ⁄ 6 (100%) in
the generalized aggressive periodontitis group (52).
P. micra was associated with both diseases, being
found in approximately one-third of the subjects and
making up approximately 4% of the total isolates
(52). The only statistically significant difference
(P = 0.036) between the subgingival microbiota of
chronic periodontitis and generalized aggressive
periodontitis was for C. rectus, with isolation fre-
quencies of 23.5% (4 ⁄ 17) for chronic periodontitis
and 50% (3 ⁄ 6) for generalized aggressive periodon-
titis (52).
In a diverse population of Colombians, Lafaurie
et al. (117) compared the relative frequencies of
putative pathogens and enteric rods in the subgingival
microbiota of individuals with chronic periodontitis
vs. generalized aggressive periodontitis. PCR methods
were used to detect the presence ⁄ absence of the
periodontal pathogens, and a culture medium selec-
tive for gram-negative enteric rods (i.e. MacConkey
agar) was used for the isolation of enteric bacteria.
No major differences were found with regard to the
percentage of patients harboring P. gingivalis for
chronic periodontitis vs. generalized aggressive
periodontitis (approximately 76% vs. approximately
73%, respectively), T. forsythia (approximately 62%
vs. approximately 54%), C. rectus (approximately
38% vs. approximately 32%), A. actinomycetemcom-
itans (approximately 17% vs. approximately 27%)
and enteric rods (approximately 30% vs. approxi-
mately 28%). Some of the periodontally healthy
control patients also harbored the pathogens:
80
P. gingivalis (14.5%), T. forsythia (3.1%), C. rectus
(22.7%), A. actinomycetemcomitans (approximately
5%) and enteric rods (approximately 27%).
Faveri et al. (45) used culture-independent molec-
ular techniques to examine the subgingival microbi-
ota at sites with probing depths ‡7 mm in ten young
adult patients diagnosed as having generalized
aggressive periodontitis. Approximately 70 taxa were
found to be prevalent, with 40 (57%) of these taxa
belonging to phylotypes for which no cultivated iso-
lates have been reported. The two most prevalent
genera detected in all patients were Selenomonas and
Streptococcus. Selenomonas sputigena was found in
nine of the ten individuals. It is noteworthy that none
of the Ôred complexÕ periodontal pathogens (i.e.
P. gingivalis, T. forsythia and Treponema denticola)
were found at any of the sites sampled in any of the
subjects (45).
Riep et al. (164) used oligonucleotide probes to
compare the subgingival prevalences of A. actino-
mycetemcomitans, P. gingivalis, P. intermedia, T.
forsythia, Treponema group II (T. denticola-like),
Treponema lecithinolyticum, C. rectus, Capnocytoph-
aga ochracea, Fusobacterium spp. and F. nucleatum
in patients with generalized aggressive periodontitis
vs. chronic periodontitis. Other individuals charac-
terized as Ôperiodontitis-resistantÕ were used as
controls. The only statistically significant difference
(P = 0.001) between the generalized aggressive perio-
dontitis and chronic periodontitis groups was a
higher prevalence of T. lecithinolyticum in the
generalized aggressive periodontitis subjects. There
was a high prevalence of P. gingivalis, P. intermedia
and T. forsythia in both periodontitis groups, but
these species were also frequently detected in the
Ôperiodontitis-resistantÕ controls (164). It is possible
that the results would have been different if
molecular probes had been used that can distinguish
between highly virulent and minimally virulent
strains of the pathogens.
Comparative microbiology of
localized aggressive periodontitis
vs. other forms of periodontitis
A classic clinical feature of localized aggressive
periodontitis is that the Ô…amount of destruction
manifested is not commensurate with the amount of
local irritants presentÕ (5). This characteristic refers to
the rather thin biofilm and lack of dental calculus
observed in some patients with the disease (5, 131).
Electron microscopic examination of teeth extracted

because of localized aggressive periodontitis revealed
relatively simple, thin, non-calcified microbial
deposits compared to the thick and complex biofilms
associated with chronic periodontitis (132). Immu-
nocytochemical analysis of the microbial deposits on
the localized aggressive periodontitis teeth showed
that many of the microorganisms were A. actinomy-
cetemcomitans (8). These observations are consis-
tent with microbiological data implicating certain
strains of A. actinomycetemcomitans in the etiology
of localized aggressive periodontitis (22, 172). An
etiological role for some strains of this microorgan-
ism is likely since their presence has been shown to
be associated with the conversion from periodontal
health to localized aggressive periodontitis (13, 49, 74,
76).
An important line of evidence that strengthens the
case for the pathogenicity of a specific microorganism
is the demonstration of a temporal relationship
between the presence of the infectious agent and
development of the disease (57). Two separate
longitudinal studies have demonstrated that carriers
of certain strains of A. actinomycetemcomitans are at
a higher risk of developing localized aggressive
periodontitis than individuals who do not harbor the
microorganisms (49, 76). In one of these studies,
periodontally healthy carriers of A. actinomycetem-
comitans (n = 38) were matched for age, gender and
race with individuals who did not harbor this organ-
ism. At the end of a 1-year follow-up period, 80% of
the A. actinomycetemcomitans-positive subjects had
developed periodontitis (defined as three pockets
‡5 mm), whereas only 10% of the A. actinomycetem-
comitans-negative individuals had this amount of
disease (49). It is of interest that disease development,
depending on the patient, was associated with any of
the three serotypes tested (i.e. a, b and c) (49).
The other longitudinal study on the microbiota
associated with initiation of localized aggressive
periodontitis followed 428 young individuals from
Morocco for 2 years (76). At the baseline visit, all
participants were free of periodontitis and subgingival
plaque samples were taken and examined by PCR for
the presence of A. actinomycetemcomitans. Included
in the battery of PCR primers were those specific for
the highly leukotoxic JP2 clone. At the end of two
years, 61 ⁄ 428 of the individuals (62.8%) lost ‡3 mm
of additional clinical attachment at one or more sites.
Individuals harboring the JP2 clone alone at baseline
had a relative risk (RR) of 18.0 (95% CI 7.8–41.2;
P < 0.001) for developing clinical attachment loss. The
relative risk value for disease development for
individuals carrying a mixture of JP2 and non-JP2
Microbiology of chronic and aggressive periodontitis
clones was 12.4 (95% CI 5.2–29.9; P < 0.001). Of all the
carriers of A. actinomycetemcomitans at baseline,
those who harbored the non-JP2 clone alone had the
lowest risk of attachment loss (RR = 3.0; 95% CI 1.3–
7.1; P = 0.012) (76). This study demonstrates that the
JP2 clone of A. actinomycetemcomitans is an impor-
tant member of the subgingival microbial community
leading to the development of localized aggressive
periodontitis in some patients. It is of interest that the
JP2 clone of A. actinomycetemcomitans appears to
have a restricted host range, in that it is carried by
individuals who can trace their heritage to the
Mediterranean area of Africa (69–73, 75). However,
there are numerous studies of localized aggressive
periodontitis developing in people who carry non-JP2
clones of A. actinomycetemcomitans (18, 49, 95, 98,
165, 206). In addition, some individuals with the
disease do not harbor the microorganism (117, 147).
Finally, as is the case with all biofilm-caused
periodontal diseases, localized aggressive periodon-
titis is not a monoinfection. It is quite likely that other
biofilm bacteria in addition to A. actinomycetem-
comitans are important in the etiopathogenesis of the
disease.
Concluding remarks
There is compelling evidence that some subgingival
microorganisms are more important than others as
etiological agents of periodontitis. However, it is clear
that chronic and aggressive forms of periodontitis
are not monoinfections. A consortium of multiple
microorganisms living in biofilms participates in the
events leading to these infections. Established peri-
odontal pathogens do not cause disease in isolation
from their neighbors within the wider microbial
community of supragingival and subgingival biofilms.
Pathogens and non-pathogens alike have co-evolved
with their human hosts, and are well adapted to
bypassing innate and adaptive immune clearance
mechanisms. The consistent finding that putative
periodontal pathogens are often found in periodon-
tally healthy people for long periods without doing any
harm supports the idea that these microorganisms are
part of the normal oral microbiota. Periodontal dis-
ease occurs when there is a disruption in the host–
microbe homeostasis associated with health. In this
context, microorganisms that cause periodontal
infections are commensal opportunistic pathogens.
Investigations on the microbiology of periodontal
infections have been hampered by wide variations in
populations surveyed, study design, disease defini-
81
Armitage
tions, sampling techniques and microbiological
methods. Despite these problems, it has been possi-
ble to make some general comparisons between the
subgingival microorganisms associated with chronic,
generalized aggressive and localized aggressive forms
of periodontitis. The microbiota found in all of these
periodontal infections shares a large number of taxa,
since the clinical samples are collected from similar
subgingival ecosystems in each case. However, it is
clear that in some, but not all, patients with classical
localized aggressive periodontitis (i.e. incisor ⁄ first
molar involvement), certain strains and clones of
A. actinomycetemcomitans appear to be important
members of the pathogenic subgingival biofilm. The
association of this microorganism with chronic and
generalized aggressive forms of periodontitis is not
strong.
Comparisons of the microbiology of chronic and
generalized aggressive forms of periodontitis are in
the early phases. Both conditions appear to be asso-
ciated with certain cultivable pathogens listed by the
1996 World Workshop in Periodontics (57), including
P. gingivalis, T. forsythia, C. rectus, Eubacterium sp.,
P. micra and Treponema sp. Application of culture-
independent microbiological methods is beginning to
reveal a longer and more diverse list of pathogens than
was possible even a few years ago. It is clear that
chronic and generalized aggressive periodontitis are
not simply gram-negative anaerobic infections, but
that gram-positive bacteria and even non-bacterial
microbes from the Archaea domain may have an eti-
ological role. Preliminary studies have suggested that
individuals with generalized aggressive periodontitis
have higher subgingival levels of Selenomonas sp. (45)
and T. lecithinolyticum (164) compared to patients
with chronic periodontitis. Based on the available
preliminary data, generalized aggressive periodontitis
and chronic periodontitis appear to be different from
a microbiological perspective. However, more
microbiological data generated by combined culture
and culture-independent methods are required from
patients with unambiguously defined cases of gener-
alized aggressive periodontitis or chronic perio-
dontitis.
References
1. Apazidou DA, Riggio MP, Kinane DF. Quadrant root plan-
ing versus same-day full-mouth root planing II. Microbio-
logical findings. J Clin Periodontol 2004: 31: 141–148.
2. Armitage GC. Periodontal diseases: diagnosis. Ann Period-
ontol 1996: 1: 37–215.
82
3. Armitage GC. Analysis of gingival crevice fluid and risk of
progression of periodontitis. Periodontol 2000 2004: 34:
109–119.
4. Asikainen S, Alaluusua S, Kari K, Kleemola-Kujala E. Sub-
gingival microflora and periodontal conditions in healthy
teenagers. J Periodontol 1986: 57: 505–509.
5. Baer PN. The case for periodontosis as a clinical entity.
J Periodontol 1971: 42: 516–520.
6. Belay N, Johnson R, Rajagopal B, DeMacario EC, Daniels L.
Methanogenic bacteria from human dental plaque. Appl
Environ Microbiol 1988: 54: 600–603.
7. Bell SD, Jackson SP. Transcription and translation in
Archaea: a mosaic of eukaryal and bacterial features.
Trends Microbiol 1998: 6: 222–228.
8. Berthold P, Listgarten MA. Distribution of Actinobacillus
actinomycetemcomitans in localized juvenile periodontitis
plaque: an electron immunocytochemical study. J Peri-
odontal Res 1986: 21: 473–485.
9. Brinig MM, Lepp PW, Ouverney CC, Armitage GC, Relman
DA. Prevalence and disease association of bacteria of
division TM7 in human subgingival plaque. Appl Environ
Microbiol 2003: 69: 1687–1694.
10. Brogan JM, Lally ET, Poulsen K, Kilian K, Demuth DR.
Regulation of Actinobacillus actinomycetemcomitans leu-
kotoxin expression: analysis of the promoter regions of
leukotoxic and minimally leukotoxic strains. Infect Immun
1994: 62: 501–508.
11. Brown JR, Doolittle WF. Archaea and the prokaryote-
to-eukaryote transition. Microbiol Mol Biol Rev 1997: 61:
456–502.
12. Brusa T, Conca R, Ferrara A, Ferrari A, Pecchioni A. The
presence of methanobacteria in human subgingival
plaque. J Clin Periodontol 1987: 14: 470–471.
13. Bueno LC, Mayer MPA, DiRienzo JM. Relationship between
conversion of localized juvenile periodontitis-susceptible
children from health to disease and Actinobacillus actino-
mycetemcomitans leukotoxin promoter structure. J Perio-
dontol 1998: 69: 998–1007.
14. Camilli A, Bassler BL. Bacterial small-molecule signaling
pathways. Science 2006: 311: 1113–1116.
15. Cavicchioli R, Curmi PM, Saunders N, Thomas T. Patho-
genic archaea: do they exist? Bioessays 2003: 25: 1119–1128.
16. Champagne CME, Buchanan W, Reddy MS, Preisser JS,
Beck JD, Offenbacher S. Potential for gingival crevice fluid
measures as predictors of risk for periodontal diseases.
Periodontol 2000 2003: 31: 167–180.
17. Chia N, Woese CR, Goldenfeld N. A collective mechanism
for phase variation in biofilms. Proc Natl Acad Sci USA
2008: 105: 14597–14602.
18. Chung H-J, Chung C-P, Son S-H, Nisengard RJ. Actino-
bacillus actinomycetemcomitans serotypes and leukotoxic-
ity in Korean localized juvenile periodontitis. J Periodontol
1989: 60: 506–511.
19. Colombo AP, Boches SK, Cotton SL, Goodson JM, Kent R,
Haffajee AD, Socransky SS, Hastrurk H, Van Dyke TE,
Dewhirst F, Paster BJ. Comparisons of subgingival microbial
profiles of refractory periodontitis, severe periodontitis, and
periodontal health using the human oral microbe identifi-
cation microarray. J Periodontol 2009: 80: 1421–1432.
20. Contreras A, Doan N, Chen C, Rusitanonta T, Flynn MJ,
Slots J. Importance of Dialister pneumosintes in human
periodontitis. Oral Microbiol Immunol 2000: 15: 269–272.

21. Conway de Macario E, Macario AJ. Methanogenic archaea
in health and disease: a novel paradigm of microbial
pathogenesis. Int J Med Microbiol 2009: 299: 99–108.
22. Cortelli JR, Cortelli SC, Jordan S, Haraszthy VI, Zambon JJ.
Prevalence of periodontal pathogens in Brazilians with
aggressive and chronic periodontitis. J Clin Periodontol
2005: 32: 860–866.
23. Costerton JW, Lewandowski Z, DeBeer D, Caldwell D,
Korber D, James G. Biofilms, the customized microniche.
J Bacteriol 1994: 176: 2137–2142.
24. Crawford JM, Taubman MA, Smith DJ. The natural history
of periodontal bone loss in germfree and gnotobiotic rats
infected with periodontopathic microorganisms. J Perio-
dontal Res 1978: 13: 316–325.
25. Cugini MA, Haffajee AD, Smith C, Kent RL Jr, Socransky SS.
The effect of scaling and root planing on the clinical and
microbiological parameters of periodontal diseases: 12-
month results. J Clin Periodontol 2000: 27: 30–36.
26. Dahlén G, Manji F, Baelum V, Fejerskov O. Putative peri-
odontopathogens in ÔdiseasedÕ and Ônon-diseasedÕ persons
exhibiting poor oral hygiene. J Clin Periodontol 1992: 19:
35–42.
27. Darveau RP. The oral microbial consortiumÕs interaction
with the periodontal innate defense system. DNA Cell Biol
2009: 28: 389–395.
28. Demmer RT, Papapanou PN. Epidemiologic patterns of
chronic and aggressive periodontitis. Periodontol 2000
2010: 53: 28–44.
29. De Soete M, Mongardini C, Pauwels M, Haffajee A, Soc-
ransky SS, van Steenberghe D, Quirynen M. One-stage full-
mouth disinfection. Long-term microbiological results
analyzed by checkerboard DNA–DNA hybridization.
J Periodontol 2001: 72: 374–382.
30. Dethlefesen L, McFall-Ngai M, Relman DA. An ecological
and evolutionary perspective on human–microbe mutual-
ism and disease. Nature 2007: 449: 811–818.
31. Dewhirst FE, Tamer MA, Ericson RE, Lay CN, Levanos VA,
Boches SK, Galvin JL, Paster BJ. The diversity of periodontal
spirochetes by 16S rRNA analysis. Oral Microbiol Immunol
2000: 15: 196–202.
32. Di Murro C, Paolantonio M, Pedrazzoli V, Lopatin DE,
Cattabriga M. Occurrence of Porphyromonas gingivalis,
Bacteroides forsythus, and Treponema denticola in peri-
odontally healthy and diseased subjects as determined by
an ELISA technique. J Periodontol 1997: 68: 18–23.
33. Dixon DR, Reife RA, Cebra JJ, Darveau RP. Commensal
bacteria influence innate status within gingival tissues: a
pilot study. J Periodontol 2004: 75: 1486–1492.
34. Doan N, Contreras A, Flynn J, Slots J, Chen C. Molecular
identification of Dialister pneumosintes in subgingival
plaque of humans. J Clin Microbiol 2000: 38: 3043–3047.
35. Dogan B, Saarela MH, Jousimies-Somer H, Alaluusua S,
Asikainen S. Actinobacillus actinomycetemcomitans sero-
type e – biotypes, genetic diversity and distribution in
relation to periodontal status. Oral Microbiol Immunol
1999: 14: 98–103.
36. Dorn BR, Dunn WA Jr, Progulske-Fox A. Bacterial interac-
tions with the autophagic pathway. Cell Microbiol 2002: 4:
1–10.
37. Doungudomdacha S, Rawlinson A, Walsh TF, Douglas CWI.
Effect of non-surgical periodontal treatment on clinical
parameters and the numbers of Porphyromonas gingivalis,
Microbiology of chronic and aggressive periodontitis
Prevotella intermedia and Actinobacillus actinomycetem-
comitans at adult periodontitis sites. J Clin Periodontol
2001: 28: 437–445.
38. Duncan L, Yoshioka M, Chandad F, Grenier D. Loss of
lipopolysaccharide receptor CD14 from the surface of hu-
man macrophage-like cells mediated by Porphyromonas
gingivalis outer membrane vesicles. Microb Pathog 2004:
36: 319–325.
39. Ebersole JL, Cappelli D, Steffen MJ. Longitudinal dynamics
of infection and serum antibody in A. actinomycetemcom-
itans periodontitis. Oral Dis 1995: 1: 129–138.
40. Eckburg PB, Lepp PW, Relman DA. Archaea and their
potential role in human disease. Infect Immun 2003: 71:
591–596.
41. Eckburg PB, Bik EM, Bernstein CN, Purdom E, Dethlefsen
L, Sargent M, Gill SR, Nelson KE, Relman DA. Diversity of
the human intestinal microbial flora. Science 2005: 308:
1635–1638.
42. Ellen RP, Galimanas VB. Spirochetes at the forefront of
periodontal infections. Periodontol 2000 2005: 38: 13–32.
43. Ellwood R, Worthington HV, Cullinan MP, Hamlet S,
Clerehugh V, Davies R. Prevalence of suspected periodontal
pathogens identified using ELISA in adolescents of differing
ethnic origins. J Clin Periodontol 1997: 24: 141–145.
44. Evans RT, Klausen B, Ramamurthy NS, Golub LM, Sfinte-
scu C, Genco RJ. Periodontopathic potential of two strains
of Porphyromonas gingivalis in gnotobiotic rats. Arch Oral
Biol 1992: 37: 813–819.
45. Faveri M, Mayer MPA, Feres M, de Figueiredo LC, Dewhirst
FE, Paster BJ. Microbiological diversity of generalized
aggressive periodontitis by 16S rRNA clonal analysis. Oral
Microbiol Immunuol 2008: 23: 112–118.
46. Filoche S, Wong L, Sissons CH. Oral biofilms: emerging
concepts in microbial ecology. J Dent Res 2010: 89: 8–18.
47. Fine DH, Kaplan JB, Kachlany SC, Schreiner HC. How we
got attached to Actinobacillus actinomycetemcomitans: a
model for infectious disease. Periodontol 2000 2006: 42:
114–157.
48. Fine DH. Dr Theodor Rosebury: grandfather of modern oral
microbiology. J Dent Res 2006: 85: 990–995.
49. Fine DH, Markowitz K, Furgang D, Fairlie K, Ferrandiz J,
Nasri C, McKiernan M, Gunsolley J. Aggregatibacter ac-
tinomycetemcomitans and its relationship to initiation of
localized aggressive periodontitis: longitudinal cohort
study of initially healthy adolescents. J Clin Microbiol 2007:
45: 3859–3869.
50. Fitzgerald RJ, Keyes PH. Demonstration of the etiologic role
of streptococci in experimental caries in the hamster. J Am
Dent Assoc 1960: 61: 9–19.
51. Fives-Taylor PM, Meyer DH, Mintz KP, Brissette C. Viru-
lence factors of Actinobacillus actinomycetemcomitans.
Periodontol 2000 1999: 20: 136–167.
52. Gajardo M, Silva N, Gómez L, León R, Parra B, Contreras A,
Gamonal J. Prevalence of periodontopathic bacteria in
aggressive periodontitis patients in a Chilean population.
J Periodontol 2005: 76: 289–294.
53. Garant PR. Light and electron microscopic observations of
osteoclastic alveolar bone resorption in rats monoinfected
with Actinomyces naeslundii. J Periodontol 1976: 47: 717–
723.
54. Gemmell E, Kjeldsen M, Yamazaki K, Nakajima T, Aldred
MJ, Seymour GJ. Cytokine profiles of Porphyromonas
83
Armitage
gingivalis-reactive T lymphocyte lines and clones derived
from P. gingivalis-infected subjects. Oral Dis 1995: 1: 139–
146.
55. Gemmell E, Yamazaki K, Seymour GJ. Destructive peri-
odontitis lesions are determined by the nature of the lym-
phocyte response. Crit Rev Oral Biol Med 2002: 13: 17–34.
56. Gemmell E, Seymour GJ. Immunoregulatory control of
Th1 ⁄ Th2 cytokine profiles in periodontal disease. Period-
ontol 2000 2004: 35: 21–41.
57. Genco R, Kornman K, Williams R, Offenbacher S, Zambon
JJ, Listgarten M, Michalowicz B, Page R, Schenkein H, Slots
J, Socransky S, Van Dyke T. Consensus report periodontal
diseases: pathogenesis and microbial factors. Ann Period-
ontol 1996: 1: 926–932.
58. Gibbons RJ, Socransky SS, Kapsimalis B. Establishment of
human indigenous bacteria in germ-free mice. J Bacteriol
1964: 88: 1316–1323.
59. Gibbons RJ, Berman KS, Knoettner P, Kapsimalis B. Dental
caries and alveolar bone loss in gnotobiotic rats infected
with capsule forming streptococci of human origin. Arch
Oral Biol 1966: 11: 549–560.
60. Gibbons RJ, Socransky SS. Enhancement of alveolar bone
loss in gnotobiotic mice harbouring human gingival bac-
teria. Arch Oral Biol 1966: 11: 847–848.
61. Gmür R, Guggenheim B. Interdental supragingival plaque –
a natural habitat of Actinobacillus actinomycetemcomitans,
Bacteroides forsythus, Campylobacter rectus, and Prevotella
nigrescens. J Dent Res 1994: 73: 1421–1428.
62. Gmür R, Marinello CP, Guggesnheim B. Periodontitis
associated bacteria in supragingival plaque of dental
hygienists: stability of carrier state and clinical develop-
ment. Eur J Oral Sci 1999: 107: 225–228.
63. Goodson JM, Tanner ACR, Haffajee AD, Sornberger GC,
Socransky SS. Patterns of progression and regression of
advanced destructive periodontal disease. J Clin Period-
ontol 1982: 9: 472–481.
64. Haffajee AD, Cugini MA, Dibart S, Smith C, Kent RL Jr,
Socransky SS. The effect of SRP on the clinical and
microbiological parameters of periodontal diseases. J Clin
Periodontol 1997: 24: 324–334.
65. Haffajee AD, Teles RD, Socransky SS. The effect of peri-
odontal therapy on the composition of the subgingival
microbiota. Periodontol 2000 2006: 42: 219–258.
66. Haraszthy VI, Hariharan G, Tinoco EMB, Cortelli JR, Lally
ET, Davis E, Zambon JJ. Evidence for the role of
highly leukotoxic Actinobacillus actinomycetemcomitans
in the pathogenesis of localized juvenile and other
forms of early-onset periodontitis. J Periodontol 2000: 71:
912–922.
67. Harper-Owen R, Dymock D, Booth V, Weightman AJ, Wade
WG. Detection of unculturable bacteria in periodontal
health and disease by PCR. J Clin Microbiol 1999: 37: 1469–
1473.
68. Hartman H, Favaretto P, Smith TF. The archaeal origins of
the eukaryotic translational system. Archaea 2006: 2: 1–9.
69. Haubek D, Poulsen K, Asikainen S, Kilian M. Evidence for
absence in northern Europe of especially virulent clonal
types of Actinobacillus actinomycetemcomitans. J Clin
Microbiol 1995: 33: 395–401.
70. Haubek D, Poulsen K, Westergaard J, Dahlén G, Kilian M.
Highly toxic clone of Actinobacillus actinomycetemcomi-
tans in geographically widespread cases of juvenile perio-
84
dontitis in adolescents of African origin. J Clin Microbiol
1996: 34: 1576–1578.
71. Haubek D, DiRienzo JM, Tinoco EMB, Westergaard J,
Lopéz NJ, Chung CP, Poulsen K, Kilian M. Racial tropism of
a highly toxic clone of Actinobacillus actinomycetemcomi-
tans associated with juvenile periodontitis. J Clin Microbiol
1997: 35: 3037–3042.
72. Haubek D, Ennibi OK, Poulsen K, Poulsen S, Benzarti N,
Kilian M. Early-onset periodontits in Morocco is associated
with the highly leukotoxic clone of Actinobacillus actino-
mycetemcomitans. J Dent Res 2001: 80: 1580–1583.
73. Haubek D, Ennibi OK, Abdellaoui L, Benzarti N, Poulsen S.
Attachment loss in Moroccan early-onset periodontitis
patients and infection with the JP2-type of Actinobacillus
actinomycetemcomitans. J Clin Periodontol 2002: 29: 657–
660.
74. Haubek D, Ennibi O-K, Poulsen K, Benzarti N, Baelum V.
The highly leukotoxic JP2 clone of Actinobacillus actino-
mycetemcomitans and progression of periodontal attach-
ment loss. J Dent Res 2004: 83: 767–770.
75. Haubek D, Poulsen K, Kilian M. Microevolution and pat-
terns of dissemination of the JP2 clone of Aggregatibacter
(Actinobacillus) actinomycetemcomitans. Infect Immun
2007: 75: 3080–3088.
76. Haubek D, Ennibi O-K, Poulsen K, Væth M, Poulsen S,
Kilian M. Risk of aggressive periodontitis in adolescent
carriers of the JP2 clone of Aggregatibacter (Actinobacillus)
actinomycetemcomitans in Morocco: a prospective longi-
tudinal cohort study. Lancet 2008: 371: 237–242.
77. Hayashi F, Okada M, Soda Y, Miura K, Kozai K. Subgingival
distribution of Campylobacter rectus and Tannerella
forsythensis in healthy children with primary dentition.
Arch Oral Biol 2006: 51: 10–14.
78. Heijl L, Wennström J, Lindhe J, Socransky SS. Periodontal
disease in gnotobiotic rats. J Periodontal Res 1980: 15: 405–
419.
79. Henderson B, Nair SP, Ward JM, Wilson M. Molecular
pathogenicity of the oral opportunistic pathogen Actino-
bacillus actinomycetemcomitans. Annu Rev Microbiol 2003:
57: 29–55.
80. Holt SC, Ebersole J, Felton J, Brunsvold M, Kornman KS.
Implantation of Bacteroides gingivalis in nonhuman pri-
mates initiates progression of periodontitis. Science 1988:
239: 55–57.
81. Holt SC, Kesavalu L, Walker S, Genco CA. Virulence factors
of Porphyromonas gingivalis. Periodontol 2000 1999: 20:
168–238.
82. Holt SC, Ebersole JL. Porphyromonas gingivalis, Trepo-
nema denticola, and Tannerella forsythia: the Ôred com-
plexÕ, a prototype polybacterial pathogenic consortium in
periodontitis. Periodontol 2000 2005: 38: 72–122.
83. Honma K, Inagaki S, Okuda K, Kuramitsu HK, Sharma A.
Role of Tannerella forsythia exopolysaccharide synthesis
operon in biofilm development. Microb Pathog 2007: 42:
156–166.
84. Honma K, Mishima E, Inagaki S, Sharma A. The OxyR
homologue in Tannerella forsythia regulates expression of
oxidative stress responses and biofilm formation. Micro-
biology 2009: 155: 1912–1922.
85. Hutter G, Schlagenhauf U, Valenza G, Horn M, Burgemei-
ster S, Claus H, Vogel U. Molecular analysis of bacteria
in periodontitis: evaluation of clone libraries, novel

phylotypes and putative pathogens. Microbiology 2003:
149: 67–75.
86. Irving JT, Socransky SS, Heeley JD. Histological changes
in experimental periodontal disease in gnotobiotic rats
and conventional hamsters. J Periodontal Res 1974: 9: 73–
80.
87. Irving JT, Newman MG, Socransky SS, Heeley JD. Histo-
logical changes in experimental periodontal disease in rats
mono-infected with a gram-negative organism. Arch Oral
Biol 1975: 20: 219–220.
88. Irving JT, Socransky SS, Tanner ACR. Histological changes
in experimental periodontal disease in rats monoinfected
with gram-negative organisms. J Periodontal Res 1978: 13:
326–332.
89. Johnson DA, Behling UA, Lai C-H, Listgarten MA, Socran-
sky SS, Nowotny A. Roles of bacterial products in
periodontitis: immune response in gnotobiotic rats
monoinfected with Eikenella corrodens. Infect Immun 1978:
19: 246–253.
90. Jordan HV, Keyes PH. Aerobic, gram-positive, filamentous
bacteria as etiologic agents of experimental periodontal
disease in hamsters. Arch Oral Biol 1964: 9: 401–414.
91. Jordan HV, Fitzgerald RJ, Stanley HR. Plaque formation and
periodontal pathology in gnotobiotic rats infected with an
oral actinomycete. Am J Pathol 1965: 47: 1157–1163.
92. Jordan HV, Keyes PH, Bellack S. Periodontal lesions in
hamsters and gnotobiotic rats infected with actinomyces of
human origin. J Periodontal Res 1972: 7: 21–28.
93. Kachlany SC, Fine DH, Figurski DH. Secretion of RTX
leukotoxin by Actinobacillus actinomycetemcomitans.
Infect Immun 2000: 68: 6094–6100.
94. Kamma J, Diamanti-Kipioti A, Nakou M, Mitsis F. Profile of
subgingival microbiota in children with mixed dentition.
Oral Microbiol Immunol 2000: 15: 103–111.
95. Kaplan JB, Schreiner HC, Furgang D, Fine DH. Popula-
tion structure and genetic diversity of Actinobacillus
actinomycetemcomitans strains isolated from localized
juvenile periodontitis patients. J Clin Microbiol 2002: 40:
1181–1187.
96. Kaplan CW, Lux R, Haake SK, Shi W. The Fusobacterium
nucleatum outer membrane protein RadD is an arginine-
inhibitable adhesin required for inter-species adherence
and the structured architecture of multispecies biofilm.
Mol Microbiol 2009: 71: 35–47.
97. Kato S, Kowashi Y, Demuth DR. Outer membrane-like
vesicles secreted by Actinobacillus actinomycetemcomi-
tans are enriched in leukotoxin. Microb Pathog 2002: 32:
1–13.
98. Kawamoto D, Ando ES, Longo PL, Nunes ACR, Wikström
M, Mayer MPA. Genetic diversity and toxic activity of
Aggregatibacter actinomycetemcomitans isolates. Oral
Microbiol Immunol 2009: 24: 493–501.
99. Keijser BJ, Zaura E, Huse SM, van der Vossen JM, Schuren
FH, Montijn RC, ten Cate JM, Crielaard W. Pyrosequencing
analysis of the oral microflora of healthy adults. J Dent Res
2008: 87: 1016–1020.
100. Keyes PH. The infectious and transmissible nature of
experimental dental caries. Findings and implications.
Arch Oral Biol 1960: 1: 304–320.
101. Keyes PH, Jordan HV. Periodontal lesions in the Syrian
hamster III. Findings related to an infectious and trans-
missible component. Arch Oral Biol 1964: 9: 377–400.
Microbiology of chronic and aggressive periodontitis
102. Kilian M, Frandsen EVG, Haubek D, Poulsen K. The etiol-
ogy of periodontal disease revisited by population genetic
analysis. Periodontol 2000 2006: 42: 158–179.
103. Klausen B, Hougen HP, Eriksen WH, Fiehn N-E. Induction
of periodontal bone loss in athymic (nude) rats monoin-
fected with streptococcus mutans. J Periodontal Res 1986:
21: 5–12.
104. Klausen B, Evans RT, Ramamurthy NS, Golub LM, Sfinte-
scu C, Lee C-Y, Bedi G, Zambon JJ, Genco RJ. Periodontal
bone level and gingival proteinase activity in gnotobiotic
rats immunized with Bacteroides gingivalis. Oral Microbiol
Immunol 1991: 6: 193–201.
105. Kolenbrander PE, Palmer RJ Jr, Rickard AH, Jakubovics NS,
Chalmers NI, Diaz PI. Bacterial interactions and succes-
sions during plaque development. Periodontol 2000 2006:
42: 47–79.
106. Krauss JL, Potempa J, Lambris JD, Hajishengallis G. Com-
plementary Tolls in the periodontium: how periodontal
bacteria modify complement and Toll-like receptor re-
sponses to prevail in the host. Periodontol 2000 2010: 52:
141–162.
107. Kreth J, Merritt J, Shi W, Qi F. Co-ordinated bacteriocin
production and competence development: a possible
mechanism for taking up DNA from neighbouring species.
Mol Microbiol 2005: 57: 392–404.
108. Kroes I, Lepp P, Relman D. Bacterial diversity within the
human subgingival crevice. Proc Natl Acad Sci USA 1999:
96: 14547–14552.
109. Kuboniwa M, Lamont RJ. Subgingival biofilm formation.
Periodontol 2000 2010: 52: 38–52.
110. Kuehbacher T, Rehman A, Lepage P, Hellmig S, Fölsch UR,
Schreiber S, Ott SJ. Intestinal TM7 bacterial phylogenies in
active inflammatory bowel disease. J Med Microbiol 2008:
57: 1569–1576.
111. Kuehn MJ, Kesty NC. Bacterial outer membrane vesicles
and the host–pathogen interaction. Genes Dev 2005: 19:
2645–2655.
112. Kulik EM, Sandmeier H, Hinni K, Meyer J. Identification of
archaeal rDNA from subgingival dental plaque by PCR
amplification and sequence analysis. FEMS Microbiol Lett
2001: 196: 129–133.
113. Kumar PS, Griffen AL, Barton JA, Paster BJ, Moeschberger
ML, Leys EJ. New bacterial species associated with chronic
periodontitis. J Dent Res 2003: 82: 338–344.
114. Kumar PS, Griffen AL, Moeschberger ML, Leys EJ. Identi-
fication of candidate periodontal pathogens and beneficial
species by quantitative 16S clonal analysis. J Clin Microbiol
2005: 43: 3944–3955.
115. Kumar PS, Leys EJ, Bryk JM, Martinez FJ, Moeschberger
ML, Griffen AL. Changes in periodontal health status are
associated with bacterial community shifts as assessed by
quantitative 16S cloning and sequencing. J Clin Microbiol
2006: 44: 3665–3673.
116. Kuramitsu HK, Chen W, Ikegami A. Biofilm formation by
periodontopathic bacteria Treponema denticola and Por-
phyromonas gingivalis. J Periodontol 2005: 76(Suppl.):
2047–2051.
117. Lafaurie GI, Contreras A, Barón A, Botero J, Mayorga-Fayad
I, Jaramillo A, Giraldo A, González F, Mantilla S, Botero A,
Archila LH, Dı́az A, Chacón T, Castillo DM, Betancourt M,
Aya MDR, Arce R. Demographic, clinical, and microbio-
logical aspects of chronic and aggressive periodontitis in
85
Armitage
Colombia: a multicenter study. J Periodontol 2007: 78: 629–
639.
118. Lai C-H, Listgarten MA, Hammond BF. Comparative
ultrastructure of leukotoxic and non-leukotoxic strains of
Actinobacillus actinomycetemcomitans. J Periodontal Res
1981: 16: 379–389.
119. Lamell CW, Griffen AL, McClellan DL, Leys EJ. Acquisition
and colonization stability of Actinobacillus actinomyce-
temcomitans and Porphyromonas gingivalis in children.
J Clin Microbiol 2000: 38: 1196–1199.
120. Lang N, Bartold PM, Cullinan M, Jeffcoat M, Mombelli A,
Murakami S, Page R, Papapanou P, Tonetti M, Van Dyke T.
Consensus report – aggressive periodontitis. Ann Period-
ontol 1999: 4: 53.
121. Landendijk PS, Kulik EM, Sandmeier H, Meyer J, Van der
Hoeven JS. Isolation of Desulfomicrobium orale sp. nov.
and Desulfovibrio strain NY682, oral sulfate-reducing
bacteria involved in human periodontal disease. Int J Syst
Evol Microbiol 2001: 51: 1035–1044.
122. Ledder RG, Gilbert P, Huws SA, Aarons L, Ashley MP, Hull
PS, McBain AJ. Molecular analysis of the subgingival mic-
robiota in health and disease. Appl Environ Microbiol 2007:
73: 516–523.
123. Lepp PW, Brinig MM, Ouverney CC, Palm K, Armitage GC,
Relman DA. Methanogenic Archaea and human perio-
dontal disease. Proc Natl Acad Sci USA 2004: 101: 6176–
6181.
124. Lewis JP. Metal uptake in host–pathogen interactions: role
of iron in Porphyromonas gingivalis interactions with host
organisms. Periodontol 2000 2010: 52: 94–116.
125. Ley RE, Peterson DA, Gordon JI. Ecological and evolu-
tionary forces shaping microbial diversity in the human
intestine. Cell 2006: 124: 837–848.
126. Leys EJ, Lyons SR, Moeschberger ML, Rumpf RW, Griffen
AL. Association of Bacteroides forsythus and a novel Bac-
teroides phylotype with periodontitis. J Clin Microbiol 2002:
40: 821–825.
127. Li CL, Jiang YT, Zhang MZ, Liang JP Identification and
quantitative analysis of Archaea involved in periodontal
disease. Zhonghua Kou Qiang Yi Xue Za Zhi 2008: 43: 589–
591 [Article in Chinese].
128. Li CL, Liu DL, Jiang YT, Zhou YB, Zhang MZ, Jiang W, Liu B,
Liang JP. Prevalence and molecular diversity of Archaea in
subgingival pockets of periodontitis patients. Oral Micro-
biol Immunol 2009: 24: 343–346.
129. Li J, Helmerhorst EJ, Leone CW, Troxler RF, Yaskell T,
Haffajee AD, Socransky SS, Oppenheim FG. Identification
of early microbial colonizers in human dental plaque.
J Appl Microbiol 2004: 97: 1311–1318.
130. Li Z, Clarke AJ, Beveridge TJ. Gram-negative bacteria pro-
duce membrane vesicles which are capable of killing other
bacteria. J Bacteriol 1998: 180: 5478–5483.
131. Liljenberg B, Lindhe J. Juvenile periodontitis. Some
microbiological, histopathological and clinical character-
istics. J Clin Periodontol 1980: 7: 48–61.
132. Listgarten MA. Structure of the microbial flora associated
with periodontal health and disease in man. A light and
electron microscopic study. J Periodontol 1976: 47: 1–18.
133. Listgarten MA, Johnson D, Nowotny A, Tanner ACR,
Socransky SS. Histopathology of periodontal disease in
gnotobiotic rats monoinfected with Eikenella corrodens.
J Periodontal Res 1978: 13: 134–138.
86
134. Lo AW, Seers CA, Boyce JD, Dashper SG, Slakeski N, Lissel
JP, Reynolds EC. Comparative transcriptomic analysis of
Porphyromonas gingivalis biofilm and planktonic cells.
BMC Microbiol 2009: 9: 18.
135. Loesche WJ. Chemotherapy of dental plaque infections.
Oral Sci Rev 1976: 9: 65–107.
136. Loos BG, Tjoa S. Host-derived diagnostic markers for
periodontitis: do they exist in gingival crvicular fluid?
Periodontol 2000 2005: 39: 53–72.
137. Loubinoux J, Bisson-Boutelliez C, Miller N, Le Faou AE.
Isolation of the provisionally named Desulfovibrio fair-
fieldensis from human periodontal pockets. Oral Microbiol
Immunol 2002: 17: 321–323.
138. Malek R, Fisher JG, Caleca A, Stinson M, van Oss CJ, Lee
J-Y, Cho M-I, Genco RJ, Ebans RT, Dyer DW. Inactivation of
the Porphyromonas gingivalis fimA gene blocks periodon-
tal damage in gnotobiotic rats. J Bacteriol 1994: 176: 1052–
1059.
139. Mans JJ, Hendrickson EL, Hackett M, Lamont RJ. Cellular
and bacterial profiles associated with oral epithelium–mic-
robiota interactions. Periodontol 2000 2010: 52: 207–217.
140. Marsh PD. Are dental diseases examples of ecological
catastrophes? Microbiology 2003: 149: 279–309.
141. Matsuki T, Watanabe K, Fujimoto J, Takada T, Tanaka R.
Use of 16S rRNA gene-targeted group-specific primers for
real-time PCR analysis of predominant bacteria in human
feces. Appl Environ Microbiol 2004: 70: 7220–7228.
142. Mayanagi G, Sato T, Shimauchi H, Takahashi N. Detection
frequency of periodontitis-associated bacteria by poly-
merase chain reaction in subgingival and supragingival
plaque of periodontitis and healthy subjects. Oral Micro-
biol Immunol 2004: 19: 379–385.
143. Mikx FHM, Matee MI, Schaeken MJM. The prevalence of
spirochetes in the subgingival microbiota of Tanzanian and
Dutch children. J Clin Periodontol 1986: 13: 289–293.
144. Miller MB, Bassler BL. Quorum sensing in bacteria. Annu
Rev Microbiol 2001: 55: 165–199.
145. Miller WD Original Investigations Concerning Pyorrhea
Alveolaris. The Micro-Organisms of the Human Mouth.
Philadelphia: S.S. White Dental Manufacturing Co., 1890:
328–334.
146. Mombelli A, Casagni F, Madianos PN. Can presence or
absence of periodontal pathogens distinguish between
subjects with chronic and aggressive periodontitis? A
systematic review J Clin Periodontol 2002: 3: 10–21.
147. Moore WEC, Moore LVH. The bacteria of periodontal
diseases. Periodontol 2000 1994: 5: 66–77.
148. Muthukuru M, Jotwani R, Cutler CW. Oral mucosal endo-
toxin tolerance induction in chronic periodontitis. Infect
Immun 2005: 73: 687–694.
149. Newman MG, Socransky SS, Savitt ED, Propas DA, Craw-
ford A. Studies on the microbiology of periodontosis.
J Periodontol 1976: 47: 373–379.
150. Okada M, Hayashi F, Nagasaka N. Detection of Actino-
bacillus actinomycetemcomitans and Porphyromonas
gingivalis in dental plaque samples from children 2 to
12 years of age. J Clin Periodontol 2000: 27: 763–768.
151. Otto K, Silhavy TJ. Surface sensing and adhesion of Esc-
herichia coli controlled by the Cpx-signaling pathway. Proc
Natl Acad Sci USA 2002: 99: 2287–2292.
152. Ouverney CC, Armitage GC, Relman DA. Single-cell enu-
meration of an uncultivated TM7 subgroup in the human

subgingival crevice. Appl Environ Microbiol 2003: 69: 6294–
6298.
153. Papaioannou W, Gizani S, Haffajee AD, Quirynen M,
Mamai-Homata E, Papagiannoulis L. The microbiota on
different oral surfaces in healthy children. Oral Microbiol
Immunol 2009: 24: 183–189.
154. Papapanou PN. Periodontal diseases: epidemiology. Ann
Periodontol 1996: 1: 1–36.
155. Papapanou PN, Sellén A, Wennström JL, Dahlén G. An
analysis of the subgingival microflora in randomly selected
subjects. Oral Microbiol Immunol 1993: 8: 24–29.
156. Paster BJ, Boches SK, Galvin JL, Ericson RE, Lau CN, Lev-
anos VA, Sahasradbudhe A, Dewhirst FE. Bacterial diversity
in human subgingival plaque. J Bacteriol 2001: 183: 3770–
3783.
157. Paster BJ, Olsen I, Aas JA, Dewhirst FE. The breadth of
bacterial diversity in the human periodontal pocket and
other oral sites. Periodontol 2000 2006: 42: 80–87.
158. Paster BJ, Dewhirst FE. Molecular microbial diagnosis.
Periodontol 2000 2009: 51: 38–44.
159. Pennisi E. Researchers trade insights about gene swapping.
Science 2004: 305: 334–335.
160. Planet PJ, Kachlany SC, Fine DH, DeSalle R, Figurski DH.
The widespread colonization island of Actinobacillus
actinomycetemcomitans. Nat Genet 2003: 34: 193–198.
161. Preza D, Olsen I, Willumsen T, Grinde B, Paster BJ. Diver-
sity and site-specificity of the oral microflora in the elderly.
Eur J Clin Microbiol Infect Dis 2009: 28: 1033–1040.
162. Prince AS. Biofilms, antimicrobial resistance, and airway
infection. N Engl J Med 2002: 347: 1110–1111.
163. Renvert S, Wikström M, Dahlén G, Slots J, Egelberg J.
Effect of root debridement on the elimination of
Actinobacillus actinomycetemcomitans and Bacteroides
gingivalis from periodontal pockets. J Clin Periodontol
1990: 17: 345–350.
164. Riep B, Edesi-Neuß L, Claessen F, Skarabis H, Ehmke B,
Flemmig TF, Bernimoulin J-P, Göbel UB, Moter A. Are
putative periodontal pathogens reliable diagnostic mark-
ers? J Clin Microbiol 2009: 47: 1705–1711.
165. Rylev M, Kilian M. Prevalence and distribution of principal
periodontal pathogens worldwide. J Clin Periodontol 2008:
8: 346–361.
166. Sakamoto M, Huang Y, Umeda M, Ishikawa I, Benno Y.
Detection of novel oral phylotypes associated with peri-
odontitis. FEMS Microbiol Lett 2002: 217: 65–69.
167. Sakamoto M, Huang Y, Ohnishi M, Umeda M, Ishikawa I,
Benno Y. Changes in oral microbial profiles after peri-
odontal treatment as determined by molecular analysis of
16S rRNA genes. J Med Microbiol 2004: 53: 563–571.
168. Schenkein HA. Host responses in maintaining periodontal
health and determining periodontal disease. Periodontol
2000 2006: 40: 77–93.
169. Shao HJ, Demuth DR. Quorum sensing regulation of
biofilm growth and gene expression by oral bacteria and
periodontal pathogens. Periodontol 2000 2010: 52: 53–67.
170. Slack E, Hapfelmeier S, Stecher B, Velykoredko Y, Stoel M,
Lawson MA, Geuking MB, Beutler B, Tedder TF, Hardt WD,
Bercik P, Verdu EF, McCoy KD, Macpherson AJ. Innate and
adaptive immunity cooperate flexibly to maintain host–
microbiota mutualism. Science 2009: 325: 617–620.
171. Slots J. Herpesviruses in periodontal diseases. Periodontol
2000 2005: 38: 33–62.
Microbiology of chronic and aggressive periodontitis
172. Slots J, Ting M. Actinobacillus actinomycetemcomitans and
Porphyromonas gingivalis in human periodontal disease:
occurrence and treatment. Periodontol 2000 1999: 20:
82–121.
173. Socransky SS, Hubersak C, Propas D. Induction of peri-
odontal destruction in gnotobiotic rats by a human oral
strain of Actinomyces naeslundii. Arch Oral Biol 1970: 15:
993–995.
174. Socransky SS. Criteria for the infectious agents in dental
caries and periodontal disease. J Clin Periodontol 1979: 6:
16–21.
175. Socransky SS, Haffajee AD. Evidence of bacterial etiology: a
historical perspective. Periodontol 2000 1994: 5: 7–25.
176. Socransky SS, Haffajee AD. Dental biofilms: difficult ther-
apeutic targets. Periodontol 2000 2002: 28: 12–55.
177. Socransky SS, Haffajee AD. Periodontal microbial ecology.
Periodontol 2000 2005: 38: 135–187.
178. Staley JT, Konopka A. Measurement of in situ activities of
nonphotosynthetic microorganisms in aquatic and terres-
trial habitats. Annu Rev Microbiol 1985: 39: 321–346.
179. Tan KS, Woo CH, Ong G, Song KP. Prevalence of Actino-
bacillus actinomycetemcomitans in an ethnic adult Chinese
population. J Clin Periodontol 2001: 28: 886–890.
180. Tanner ACR, Milgrom PM, Kent R Jr, Mokeem SA, Page RC,
Riedy CA, Weinstein P, Bruss J. The microbiota of young
children from tooth and tongue samples. J Dent Res 2002:
81: 53–57.
181. Tanner ACR, Izard J. Tannerella forsythia, a periodontal
pathogen entering the genomic era. Periodontol 2000 2006:
42: 88–113.
182. Taubman MA, Yoshie H, Wetherell JR Jr, Ebersole JL, Smith
DJ. Immune response and periodontal bone loss in
germfree rats immunized and infected with Actinobacillus
actinomycetemcomitans. J Periodontal Res 1983: 18: 393–
401.
183. Taubman MA, Haffajee AD, Socransky SS, Smith DL, Eb-
ersole JL. Longitudinal monitoring of humoral antibody in
subjects with destructive periodontal disease. J Periodontal
Res 1992: 27: 511–521.
184. Teles RP, Haffajee AD, Socransky SS. Microbial goals of
periodontal therapy. Periodontol 2000 2006: 42: 180–218.
185. Tlaskalová-Hogenová H, Stephánková R, Hudcovic T,
Tucková L, Cukrowska B, Lodinová-Zádniková R, Kozáková
H, Rossmann P, Bártová J, Sokol D, Funda DP, Borovská D,
Reháková Z, Sinkora J, Hofman J, Drastich P, Kokesová A.
Commensal bacteria (normal microflora), mucosal immu-
nity and chronic inflammatory and autoimmune diseases.
Immunol Lett 2004: 93: 97–108.
186. Tribble GD, Lamont GJ, Progulske-Fox A, Lamont RJ.
Conjugal transfer of chromosomal DNA contributes to
genetic variation in the oral pathogen Porphyromonas
gingivalis. J Bacteriol 2007: 189: 6382–6388.
187. Valenza G, Veihelmann S, Peplies J, Tichy D, Roldan-Pareja
MC, Schlagenhauf U, Vogel U. Microbial changes in peri-
odontitis successfully treated by mechanical plaque
removal and systemic amoxicillin and metronidazole. Int J
Med Microbiol 2009: 299: 427–438.
188. Vanhoutte T, Huys G, De Brandt E, Swings J. Temporal
stability analysis of the microbiota in human feces by
denaturing gel electrophoresis using universal and group-
specific 16S rRNA gene primers. FEMS Microbiol Ecol 2004:
48: 437–446.
87
Armitage
189. Van Winkelhoff AJ, Loos BG, van der Reijden WA, van der
Velden U. Porphyromonas gingivalis, Bacteroides forsythus
and other putative periodontal pathogens in subjects with
and without periodontal destruction. J Clin Periodontol
2002: 29: 1023–1028.
190. Vartoukian SR, Palmer RM, Wade WG. Diversity and
morphology of members of the phylum ÔSynergistetesÕ in
periodontal health and disease. Appl Environ Microbiol
2009: 75: 3777–3786.
191. Vianna ME, Holtgraewe S, Seyfarth I, Conrads G, Horz HP.
Quantitative analysis of three hydrogenotrophic microbial
groups, methanogenic Archaea, sulfate-reducing bacteria,
and acetogenic bacteria, within plaque biofilms associated
with human periodontal disease. J Bacteriol 2008: 190:
3779–3785.
192. Vianna ME, Conrads G, Gomes BPFA, Horz HP. T-RFLP-
based mcrA gene analysis of methanogenic archaea in
association with oral infections and evidence of a novel
Methanobrevibacter phylotype. Oral Microbiol Immunol
2009: 24: 417–422.
193. Vlassov VV, Laktionov PP, Rykova EY. Extracellular nucleic
acids. Bioessays 2007: 29: 654–667.
194. Whiteley M, Bangera G, Bumgarner RE, Parsek MR, Teitzel
GM, Lory S, Greenberg EP. Gene expression in Pseudomo-
nas aeruginosa biofilms. Nature 2001: 413: 860–864.
195. Wilson BA, Salyers AA. Is the evolution of bacterial patho-
gens an out-of-body experience? Trends Microbiol 2003: 11:
347–350.
196. Wilson M, Lopatin D, Osborne G, Kieser JB. Prevalence of
Treponema denticola and Porphyromonas gingivalis in
plaque from periodontally-healthy and periodontally-
diseased sites. J Med Microbiol 1993: 38: 406–410.
197. Wilson MJ, Weightman AJ, Wade WG. Applications of
molecular biology in the characterisation of uncultured
microorganisms associated with human disease. Rev Med
Microbiol 1997: 8: 91–101.
198. Wyss C, Guggesnheim B. Effects of the association of
conventional rats with Actinomyces viscosus Nyl and
Bacteroides gingivalis W83. J Periodontal Res 1984: 19:
574–577.
88
199. Xie H, Cook GS, Costerton JW, Bruce G, Rose TM, Lamont
RJ. Intergeneric communication in dental plaque biofilms.
J Bacteriol 2000: 182: 7067–7069.
200. Ximénez-Fyvie LA, Haffajee AD, Socransky SS. Comparison
of the microbiota of supra- and subgingival plaque in
health and periodontitis. J Clin Periodontol 2000: 27: 648–
657.
201. Yamabe K, Maeda H, Kokeguchi S, Tanimoto I, Soni N,
Asakawa S, Takashiba S. Distribution of Archaea in Japa-
nese patients with periodontitis and humoral immune re-
sponse to the components. FEMS Microbiol Lett 2008: 287:
69–75.
202. Yamanaka T, Furukawa T, Matsumoto-Mashimo C, Ya-
mane K, Sugimori C, Nambu T, Mori N, Nishikawa H,
Walker CB, Leung KP, Fukushima H. Gene expression
profile and pathogenicity of biofilm-forming Prevotella
intermedia strain 17. BMC Microbiol 2009: 9: 11.
203. Yang EY, Tanner ACR, Milgrom P, Mokee SA, Riedy CA,
Spadafora AT, Page RC, Bruss JON. Periodontal pathogen
detection in gingival ⁄ tooth and tongue flora samples from
18- to 48-month-old children and periodontal status of
their mothers. Oral Microbiol Immunol 2002: 17: 55–59.
204. Yang H-W, Asikainen S, Dogan B, Suda R, Lai C-H. Rela-
tionship of Actinobacillus actinomycetemcomitans sero-
type b to aggressive periodontitis: frequency in pure
cultured isolates. J Periodontol 2004: 75: 592–599.
205. Yilmaz Ö, Verbeke P, Lamont RJ, Ojcius DM. Intercellular
spreading of Porphyromonas gingivalis infection in
primary gingival epithelial cells. Infect Immun 2006: 74:
703–710.
206. Zambon JJ, Haraszthy VI, Hariharan G, Lally ET, Demuth
DR. The microbiology of early-onset periodontitis: associ-
ation of highly toxic Actinobacillus actinomycetemcomitans
strains with localized juvenile periodontitis. J Periodontol
1996: 67: 282–290.
207. Zimmer W, Wilson M, Marsh PD, Newman HN, Bulman J.
Porphyromonas gingivalis, Prevotella intermedia and Acti-
nobacillus actinomycetemcomitans in the plaque of chil-
dren without periodontitis. Microb Ecol Health Dis 1991: 4:
329–336.