MCQs For Oral Microbiology PDF

MCQs for
Oral Microbiology
This page intentionally left blank
MCQs for
Oral Microbiology
Elsevier Ltd.
Revised and Updated Edition

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CONTENTS
Preface vii
Acknowledgments viii
1 Introduction 1
2 The Mouth as a Microbial Habitat 5
3 The Resident Oral Microflora 20
4 Acquisition, Adherence, Distribution and Metabolism
of the Oral Microflora 37
5 Dental Plaque 59
6 Plaque-Mediated Diseases—Dental Caries and
Periodontal Diseases 75
7 Orofacial Bacterial Infections 101

8 Antimicrobial Prophylaxis 118
9 Oral Fungal Infections 130
10 Orofacial Viral Infections 143
11 Oral Implications of Infection in Compromised Patients 155
12 Infection Control 173
Index 187
v
PREFACE
For students, a good way to test their understanding and knowledge about a particular subject
and to prepare for exams is to practice using Multiple Choice Questions (MCQs). This book on
MCQs for Oral Microbiology has been written keeping in mind the above purpose.
In this book Elsevier has worked with professional question writers to prepare a collection of
500 MCQs to accompany the subject matter covered in each chapter of the textbook, Oral
Microbiology, 5th edition by Philip D. Marsh and Michael V. Martin (ISBN: 978-0-443-10144-1).
The style of MCQs is three distractors and one correct answer so the student will need to mark
the correct option accordingly. Each chapter is followed by a feedback section showing the correct
answers and a very quick rationale why each answer is correct or incorrect thus elevating student’s
confidence to answer many more MCQs on the subject. Below each rationale, reference to the
page number of the main textbook, Oral Microbiology, is given for the students who want to revise
or study the particular topic again.
The aim for the student is to get as many correct as possible, and to revise any subject
area where the number of correct marks is low. We sincerely hope that students will find the book
extremely useful. We welcome comments and suggestions from students and teachers, which will
help in improving this book further.
Elsevier Ltd.
vii
ACKNOWLEDGMENTS
The publisher would like to thank Professor P. D. Marsh and Professor D. W. Williams for their
insightful feedback in reviewing this book. The publisher would also like to thank Sherry Castle
Boyer and her team for their efforts in preparing the multiple choice questions.
viii
C H A P T E R 1
Introduction
Multiple Choice
1. In microbial ecology, which of the following terms describes the site where microorganisms
grow?
a. Niche.
b. Habitat.
c. Ecosystem.
d. Community.
2. Which of the following is true about resident microflora of a host?

a. The microflora has a passive relationship with its host.
b. Resident microflora contributes directly to the normal development of the defence
systems of the host.
c. Resident microflora is the same for each individual.
d. Resident microflora make up around 10% of cells of the human body.
3. An example of an endogenous source that can create a change in the biology of the mouth
would be which of the following?
a. Change in the integrity of the host defences.
b. Use of an antimicrobial oral rinse.
c. Antibiotic treatment.
d. Increase in the intake of fermentable carbohydrates.
4. The mouth can act as a reservoir for which of the following pathogens?
a. Helicobacter pylori.
b. Pseudomonas aeruginosa.
c. Respiratory pathogens.
d. All of the above.
5. The microbial colonisation of all environmentally accessible surfaces of the body begins at
which of the following?
a. Birth.
b. Breast-feeding.
c. One month post-breast feeding.
d. Eating solid foods.
6. Streptococci are not a resident human microflora of which of the following sites?
a. Nasopharynx.
b. Mouth.
c. Uro-genital tract.
d. Gut.
1
2 1—Introduction
7. The human body is estimated to be made up of 1014 cells; what proportion are
microorganisms?
a. <0.01%.
b. 1%.
c. 20%.
d. 90%.
8. Of the following, which is not a reason for disparities in oral healthcare within a
population?
a. Socio-economic status.
b. Race.
c. Lack of dental education.
d. Ethnicity.
9. What is the term used to describe the growth of microorganisms on a surface?

a. Microbial community.
b. Biofilm.
c. Niche.
d. Ecosystem.
10. Evidence suggests that oral disease can affect the general health of an individual by which
of the following means?
a. Factors affecting general health can enter the bloodstream via the highly vascularised
periodontium.
b. A genetic predisposition to a systemic disease.
c. The presence of non-opportunistic pathogens in the mouth.
d. Inadequate nutrition.
Feedback
1. ANS: b
a. The ‘niche’ is the ‘function’ or ‘role’ of a microorganism in a habitat.
b. Correct. The habitat is defined as the site where microorganisms grow.
c. Ecosystem is a combination of the microorganisms and the habitat together with the
biotic and abiotic surroundings.
d. The mixture of microorganisms growing in a particular habitat is a microbial
community.
REF: Microbial ecology, pp. 4–5
2. ANS: b
a. The microflora has a contributory relationship with its host.
b. Correct. Resident microflora contributes directly to the normal development of the
defence systems of the organism.
c. Resident microflora is distinct for each individual.
d. Resident microflora make up significantly more than 10% of cells of the human body.
REF: The human microflora, pp. 1–2

1—Introduction 3
3. ANS: a
a. Correct. Endogenous changes such as alterations in the integrity of the host defences
due to drug therapy perturb the natural stability of the microflora.
b. Major changes to the biology of the mouth from exogenous sources include antibiotic
treatment, use of antimicrobial oral rinses, or the frequent intake of fermentable carbo-
hydrates in the diet.
c. Major changes to the biology of the mouth from exogenous sources include antibiotic
d. Major changes to the biology of the mouth from exogenous sources include antibiotic
REF: The oral microflora in health and disease, pp. 2–3
4. ANS: d
a. Helicobacter pylori can be detected in dental plaque on occasions.
b. Pseudomonas aeruginosa can colonise the mouth of patients with cystic fibrosis.
c. Respiratory pathogens can be detected in dental plaque in patients in intensive care.
d. Correct. All of these potential pathogens can be detected in the mouth on occasions.
REF: The oral microflora in general health, pp. 5–6
5. ANS: a
a. Correct. The microbial colonisation of all environmentally accessible surfaces of the body
(both external and internal) begins at birth. Such surfaces are exposed to a wide range
of microorganisms derived from the environment and from other persons.
b. The microbial colonisation of all environmentally accessible surfaces of the body (both
external and internal) begins at birth.
c. The microbial colonisation of all environmentally accessible surfaces of the body (both
d. The microbial colonisation of all environmentally accessible surfaces of the body (both
REF: The human microflora, p. 2
6. ANS: d
a. Streptococcus is a resident human microflora of the mouth, nasopharynx, and uro-genital
tract. It is not a major resident of the gut.
b. Streptococcus is a resident human microflora of the mouth, nasopharynx, and uro-genital
c. Streptococcus is a resident human microflora of the mouth, nasopharynx, and uro-genital
d. Correct. Streptococcus is a resident human microflora of the mouth, nasopharynx, and
uro-genital tract, but not of the gut.
REF: The human microflora, Figure 1.1, p. 2

4 1—Introduction
7. ANS: d
a. The human microbiome is estimated to make up 90% of the cells of the human body.
b. The human microbiome is estimated to make up 90% of the cells of the human body.
c. The human microbiome is estimated to make up 90% of the cells of the human body.
d. Correct. The human microbiome is estimated to make up 90% of the cells of the human
body.
REF: The human microflora, Figure 1.1, pp. 1–2
8. ANS: c
a. Profound disparities in oral health exist within a population due to differences in socio-
economic status (SES) and race or ethnicity.
b. Profound disparities in oral health exist within a population due to differences in socio-
c. Correct. Lack of dental education is not a reason profound disparities in oral health exist
within a population.
d. Profound disparities in oral health exist within a population due to differences in socio-
REF: The scale of oral disease, p. 3
9. ANS: b
a. A microbial community is a mixture of interacting microorganisms, but these do not have
to be on a surface, although this is where they are normally found.
b. Correct. A biofilm is the term used to describe microorganisms growing on a surface.
c. The niche describes the ‘function’ or ‘role’ of a microorganism within a microbial
community.
d. The ecosystem is a combination of the microorganisms and the habitat together with the
biotic and abiotic surroundings.
REF: Microbial ecology, pp. 4–5
10. ANS: a
a. Correct. Factors of infection entering the bloodstream via the highly vascularised peri-
odontium are now believed to affect distant sites in the body.
b. A genetic predisposition to a systemic disease does not necessarily influence the relation-
ship between oral and systemic disease.
c. The presence of non-opportunistic pathogens in the mouth does not affect general health.
d. Inadequate nutrition is a contributing factor to oral disease but not the link between oral
and systemic health.
REF: Oral microflora and general health, p. 5

C H A P T E R 2
The Mouth as a Microbial Habitat
Multiple Choice
1. The large masses of microorganisms that accumulate on the hard, non-shedding surface of
the oral cavity are described by which of the following terms?
a. Flocs.
b. Aggregates.
c. Biofilms.
d. Microcosm.
2. The shift in oral microflora composition that fosters overgrowth by Gram negative species
due to a block in salivary flow in sedated patients in intensive care can lead to which of the
following?
a. Desquamation.
b. Increase in gingival crevicular fluid (GCF) flow.
c. Pulmonary complications.
d. Increase in defensins.
3. Which of the following does not facilitate a change in the ecology of the oral cavity?
a. Reduction in salivary flow.
b. Type of food ingested.
c. Pyrexia.
d. Dental treatment.
4. Which of the following surfaces acts as a habitat for the largest number of microorganisms
that otherwise might be removed by the flow of saliva or masticatory forces?
a. Lips.
b. Cheeks.
c. Tongue.
d. Palate.
5. Which of the following oral surfaces is non-shedding and facilitates microbial colonisation?
a. Oral mucosa.
b. Vestibular surface.
c. Enamel surface.
d. Palate.
6. Which of the following are not innate host defence peptides?

a. sIgA.
b. Cystatins.
c. Secretory leucocyte proteinase inhibitor (SLPI).
d. Tissue inhibitors of metalloproteinases (TIMP).
5
6 2—The Mouth as a Microbial Habitat
7. Which of the following salivary components do not play a key role in controlling bacterial
and fungal colonisation of the mouth?
a. Minerals.
b. Salivary mucins.
c. Salivary lactoperoxidase.
d. Cathelicidin.
8. Which of the following is not part of the adaptive host response in the mouth?
a. IgG.
b. IgM.
c. IgA.
d. Lysozyme.
9. Mucins play a role in which of the following?

a. Providing support to cell walls.
b. Inhibiting glycolysis.
c. Blocking of inflammatory mediators.
d. Being a source of nutrients for oral bacteria.
10. Which of the following is not a tissue that is part of the tooth structure?
a. Cementum.
b. Gingiva.
c. Dentin.
d. Enamel.
11. Which of the following affords colonising microorganisms the most protection from the
adverse conditions in the mouth?
a. Dorsum of the tongue.
b. Unattached gingiva.
c. Occlusal surface of tooth.
d. Gingival crevice.
12. Which of the following is an area/surface in the oral cavity used for acquiring subgingival
plaque samples?
a. Occlusal aspect.
b. Mucosal surfaces.
c. Dorsum of tongue.
13. Which of the following is not a factor by which saliva influences the microflora of the mouth?
a. Formation of a conditioning film.
b. Providing proteins and glycoproteins for bacterial growth.
c. Providing a neutral pH and acting as a buffer for microbial growth.
d. Delivering neutrophils and complement to kill microorganisms.
14. Which of the following tooth surfaces provide the most protection to microorganisms in
the oral cavity?
a. Lingual surfaces.
b. Approximal areas.
c. Buccal surfaces.
d. Pits and fissures.
2—The Mouth as a Microbial Habitat 7
15. Which of the following tooth surfaces are associated with the lowest microbial communities
and disease?
a. Smooth surfaces.
b. Approximal surfaces.
c. Root surfaces.
d. Pits and fissures.
16. Which of the following is found in the highest concentration in saliva compared
with GCF?
a. IgG.
b. Amylase.
c. Calcium.
d. Protein.
17. Saliva enters the mouth through major salivary ducts including which of the following?
a. Submandibular and buccal glands.
b. Parotid, submandibular and sublingual glands.
c. Labial and lingual glands.
d. Buccal and palatal glands.
18. Which of the following is found in the highest concentration in GCF compared with saliva?
a. IgM.
b. Lysozyme.
c. Phosphate.
d. Potassium.
19. The major buffering system in saliva is made of which of the following?
a. Bicarbonate.
b. Phosphates.
c. Peptides.
d. Proteins.
20. Why is it important to limit the consumption of sugary drinks or food prior to sleeping?
a. Causes halitosis.
b. Increases the risk of becoming diabetic.
c. Fractures restorations.
d. Encourages dental caries.
21. The major organic components of saliva (proteins and glycoproteins) influence the oral
microflora in which of the following ways?
a. Limiting the ability of all microorganisms to attach to the tooth surface.
b. Acting as a primary source of nutrients.
c. Preventing colonisation.
d. Increasing colonisation of Gram negative organisms only.
22. Following the dietary intake of fermentable carbohydrates, the metabolism of which of the
following contributes to the rise in pH?
a. Sodium.
b. Calcium.
c. Amino acids.
d. Albumin.
23. Which is the class of enzyme responsible for removing carbohydrates from the side chains
of salivary mucins?
a. Glucosyltransferase.
b. Glycosidase.
c. Fructosyltransferase.
d. Amylase.
24. Ninety-five percent of the leukocytes in GCF are which of the following types?
a. Neutrophils.
b. Lymphocytes.
c. Monocytes.
d. Macrophages.
25. Which aspect of the oral cavity provides stable conditions suitable for the growth of a wide
range of microorganisms?
a. A high pH.
b. Gingival crevicular fluid secretion.
c. Antibody production.
d. Relatively constant temperature.
26. A rise in the temperature in a periodontal pocket can signal which of the following events?
a. Root caries.
b. A diminished flow of GCF.
c. Inflammation.
d. Halitosis.
27. Of the following, which environmental factor most governs the survival and relative growth
of obligately anaerobic organisms?
a. High pH.
b. Low pH.
c. Increased oxygen levels.
d. Low oxidation-reduction potential.
28. Oxidation-reduction level at a site is usually expressed as which of the following?

a. Eh.
b. Percentage oxygen level.
c. pH.
d. Oxygen consumption ratio.
29. Oral microorganisms are separated into aerobes and anaerobes based on which of the fol-
lowing characteristics?
a. Grows in plaque biofilm.
b. Grows in the absence or presence of oxygen.
c. Grows in the absence or presence of hydrogen.
d. Grows in the presence or absence of carbon dioxide.
30. Lactobacillus species prefer to grow at which of the following conditions?

a. Neutral pH.
b. Acidic pH.
c. Alkaline pH.
31. The persistence and diversity of the resident oral microflora on mucosal surfaces is primarily
due to the metabolism of which of the following?
a. GCF.
b. Dietary factors.
c. Endogenous nutrients provided by the host.
d. Exopolymers.
32. Despite the complexity of ingested food, the metabolism of which class of compound sig-
nificantly influences the ecology of the mouth?
a. Nitrate in green vegetables.
b. Dairy products.
c. Fermentable carbohydrates.
d. Xylitol.
33. An alternative terminology for non-specific and specific host defence factors is which of the
following?
a. Hydrophilic and bacterial aggregating factors.
b. Innate immunity and adaptive immunity factors.
c. Antigen activity and broad spectrum factors.
d. Physiochemical and immunological barriers.
34. Microorganisms are unable to maintain themselves in saliva by cell division alone due to
which of the following factors?
a. Chewing.
b. GCF flow.
c. Swallowing.
d. Reduced saliva flow.
35. Defensins are a family of peptides that have which of the following properties?
a. Specific antifungal activity.
b. Neutralising potentially inflammatory processes.
c. Inhibition of glycolysis by plaque bacteria.
d. Broad spectrum antimicrobial activity (antibacterial, antifungal and antiviral activity).
36. Porphyromonas gingivalis is an obligate anaerobe which prefers to grow at

a. Neutral pH.
b. Acidic pH.
c. Alkaline pH.
37. Which is the predominant immunoglobulin in saliva?

a. Secretory IgA.
b. IgG.
c. IgM.
d. IgA.
38. An analysis of the microflora of twin children living together revealed which of the
following?
a. Microflora of identical twins was less similar than that of fraternal twins.
b. There was no difference between the microflora of identical twins from that of fraternal twins.
c. Microflora of identical twins was more similar than that of fraternal twins.
d. There is no relationship of microflora to any aspect of the relationship of children to
each other.
39. Currently, the most potent antimicrobial agent(s) available in a mouthrinse is which of the
following?
a. Sodium lauryl sulphate.
b. Plant extracts.
c. Chlorhexidine.
d. Fluoride.
40. Taking high doses of penicillin or erythromycin can result in which of the following oral
sequela?
a. Reduction in salivary flow.
b. Overgrowth by yeasts or the emergence of antibiotic-resistant bacteria.
c. Development of acid-tolerating organisms.
d. An increased presence of histatins.
Feedback
1. ANS: c
a. Flocs are aggregates of microorganisms, but the term is not used to describe bacteria on
teeth.
b. Aggregates are clumps of microorganisms, but the term is not used to describe bacteria
on teeth.
c. Correct. Biofilm is a mass of microorganisms that accumulates on oral surfaces.
d. A microcosm is a laboratory simulation of a microbial ecosystem, but is not used to
describe the bacteria on a tooth surface.
REF: The mouth as a microbial habitat, p. 8
2. ANS: c
a. Desquamation is the natural shedding of epithelial cells and is not the result of a blockage
to salivary flow.
b. An increase in GCF is not the result of a blockage to salivary flow.
c. Correct. When saliva flow is blocked (for example, in sedated patients in intensive care)
a shift in the composition of the oral microflora can occur resulting in overgrowth by
Gram negative species, and this can lead to pulmonary complications.
d. An increase in defensins is not the result of a blockage to salivary flow.
REF: Innate immunity, p. 18

3. ANS: c
a. A reduction in salivary flow can change the ecology of the oral cavity.
b. The types of food ingested, such as carbohydrates, can alter the pH balance and the
ecology of the oral cavity.
c. Correct. An increase or decrease in body temperature does not facilitate a change in the
ecology of the oral cavity.
d. Dental treatments, such as scaling, placement of restorations or insertion of orthodontic
bands, can cause transient fluctuations in the stability of the oral ecosystem.
4. ANS: c
a. Lips do not provide refuge for many microorganisms which would otherwise be removed
by mastication and the flow of saliva.
b. Cheeks do not provide refuge for many microorganisms which would otherwise be
removed by mastication and the flow of saliva.
c. Correct. The papillary structure of the dorsum of the tongue provides refuge for many
microorganisms which would otherwise be removed by mastication and the flow of saliva.
d. The palate does not provide refuge for many microorganisms which would otherwise be
removed by mastication and the flow of saliva.
5. ANS: c
a. Oral mucosa is not a non-shedding surface.
b. Vestibular surface is not a non-shedding surface.
c. Correct. Enamel provides hard non-shedding surfaces for microbial colonisation.
d. Palate is not a non-shedding surface.
REF: Teeth, p. 9
6. ANS: a
a. Correct. sIgA is an immunoglobulin and forms part of the adaptive immune response.
b. Cystatins are antimicrobial peptides and form part of the innate host defences.
c. SLPI is part of the innate host defences.
d. TIMP are part of the innate host defences.
REF: Innate immunity, p. 20
7. ANS: a
a. Correct. While present in saliva, minerals do not play a role in controlling bacterial and
fungal colonisation of the mouth.
b. Salivary mucins play a key role in controlling bacterial and fungal colonisation of the
mouth.
c. Salivary lactoperoxidase is an antimicrobial factor that plays a role in controlling bacterial
and fungal colonisation of the mouth.
d. Cathelicidin is an antimicrobial peptide that plays a role in controlling bacterial and
fungal colonisation of the mouth.
REF: Saliva, p. 12
8. ANS: d
a. IgG is an immunoglobulin and forms part of the adaptive host response.
b. IgM is an immunoglobulin and forms part of the adaptive host response.
c. IgA is an immunoglobulin and forms part of the adaptive host response.
d. Correct. Lysozyme is part of the innate host response.
REF: Innate immunity, pp. 18–20
9. ANS: d
a. Mucins may interact with salivary components to enhance their antimicrobial activities,
but do not provide support to cell walls.
b. Mucins may interact with salivary components to enhance their antimicrobial activities,
but do not inhibit glycolysis.
c. Mucins may interact with salivary components to enhance their antimicrobial activities,
but do not play a role in the blocking of inflammatory mediators.
d. Correct. Mucins act as primary sources of nutrients for the oral microflora.
REF: Saliva, p. 11
10. ANS: b
a. Cementum is a tissue that is part of the tooth structure.
b. Correct. The gingiva is not a tissue that is part of the tooth structure; rather, it is a sup-
portive tissue.
c. Dentine is a tissue that is part of the tooth structure.
d. Enamel is a tissue that is part of the tooth structure.
REF: Teeth, p. 9
11. ANS: d
a. The gingival crevice, not the dorsum of the tongue, provides the most protection to colo-
nising microorganisms from the adverse conditions in the mouth.
b. The architecture of unattached gingiva does not provide protection to colonising
microorganisms.
c. The occlusal tooth surface is actively involved in the chewing process and does not
provide protection to colonising microorganisms.
d. Correct. Due to the unique architecture, the gingival crevice affords the most protection
to colonising microorganisms from the adverse conditions in the mouth.
REF: Teeth, p. 10
12. ANS: d
a. The pits and fissures of the occlusal surface do collect plaque; however, they are not a
subgingival surface.
b. Plaque does not adhere to mucosal surfaces.
c. Gingival crevicular fluid does not provide the surface structure necessary for plaque
accumulation.
d. Correct. The gingival crevice is the location from which subgingival plaque can be
sampled.
REF: Teeth, p. 10
13. ANS: d
a. Saliva is adsorbed onto teeth to form the acquired pellicle, which promotes bacterial
attachment.
b. Saliva contains molecules that can be used as primary nutrients for bacterial
growth.
c. Most oral bacteria prefer a neutral pH for growth.
d. Correct. Neutrophils and complement are delivered to the gingival crevice via GCF.
REF: GCF, pp. 12–14, Figure 2.6, p. 11
14. ANS: b
a. The smooth lingual surface of the tooth with its approximation to the tongue is not the
most conducive location to support microbial colonisation.
b. Correct. The stagnant approximal areas between adjacent teeth afford protection to colo-
nising microorganisms.
c. The smooth buccal surface of the tooth with its proximity to the check is not the most
conducive location to support microbial colonisation.
d. Pits and fissures of the occlusal surface do harbour microorganism; however, they do not
offer the most protection to the organisms.
REF: Teeth, p. 10
15. ANS: a
a. Correct. The smooth surface of the tooth is the least conducive location to support
microbial colonisation.
b. The stagnant approximal areas between adjacent teeth afford protection to colonising
microorganisms.
c. The root surface is a conducive location to support microbial colonisation.
d. Pits and fissures of the occlusal surface offer the protection required to support
colonisation.
REF: Teeth, p. 10
16. ANS: b
a. IgG is present at low levels in saliva.
b. Correct. Amylase is found in higher concentrations in saliva compared with GCF.
c. Calcium is present at a lower concentration in saliva than GCF.
d. Protein is present at a high concentration in GCF.
REF: Saliva, Table 2.2, p. 11
17. ANS: b
a. The submandibular salivary gland is considered one of the major glands, while the buccal
glands are considered minor glands.
b. Correct. Salvia enters the oral cavity via salivary ducts from the major parotid, sub-
mandibular and sublingual glands.
c. Labial and lingual glands are considered minor salivary glands.
d. Buccal and palatal glands are considered minor salivary glands.
REF: Saliva, p. 11
18. ANS: a
a. Correct. IgM is present at higher concentrations in GCF.
b. Lysozyme is found mainly in saliva.
c. Phosphate is found in both fluids; it is higher in saliva.
d. Potassium is found in both fluids at a similar concentration.
REF: Saliva, Table 2.2, p. 11
19. ANS: a
a. Correct. Bicarbonate is the major buffering system in saliva affecting the pH of saliva
with a mean range of 6.75 and 7.25.
b. Phosphates also play a role in the buffering system but are not the major component.
c. Peptides also play a role in the buffering system but are not the major component.
d. Proteins also play a role in the buffering system but are not the major component.
REF: Saliva, p. 11
20. ANS: d
a. Halitosis is caused primarily by bacteria that colonise the tongue, not especially related
to sleep times nor the consumption of sugary drinks and food.
b. While an increase in sugar consumption may increase one’s risk of becoming diabetic,
when it is consumed it is not a confounding factor.
c. Dental restorations are not fractured by the consumption of carbohydrates at sleep time.
d. Correct. Sugar can be metabolised to acids by dental plaque, which can cause deminer-
alisation. The concentration of selected components and flow rate of saliva have a circa-
dian rhythm with the slowest flow of saliva being during sleep, which limits the protective
function of saliva.
REF: Saliva, p. 11
21. ANS: b
a. The major organic components of saliva (proteins and glycoproteins) adsorb to the tooth
surface to form a film (the acquired pellicle) which promotes the attachment of many
microorganisms.
b. Correct. The major organic components of saliva (proteins and glycoproteins) influence
the oral microflora by acting as the primary source of nutrients (carbohydrates and pro-
teins) for the resident microflora.
c. The major organic components of saliva (proteins and glycoproteins) promote microbial
colonisation by forming the acquired pellicle.
d. The major organic components of saliva (proteins and glycoproteins) provide the nutri-
ents for the growth and the acquired pellicle for colonisation of both Gram positive and
Gram negative organisms.
REF: Saliva, p. 11
22. ANS: c
a. Sodium is a component of whole saliva and GCF.
b. Calcium is a component of whole saliva and GCF.
c. Correct. The metabolism of amino acids, peptides, proteins and urea can lead to a rise
in pH after the dietary intake of fermentable carbohydrates.
d. Albumin is a component of whole saliva and GCF.
REF: Saliva, p. 12
23. ANS: b
a. Glycosyltransferases remove glucose from sucrose to form glucans.
b. Correct. Various glycosidases remove different carbohydrates from the side chains of
salivary mucins.
c. Fructosyltransferases remove fructose from sucrose to form fructans.
d. Amylase is involved in the breakdown of starch.
REF: Nutrients, p. 16
24. ANS: a
a. Correct. GCF contains leukocytes, 95% of which are neutrophils.
b. GCF contains leukocytes, 95% of which are neutrophils, the remainder being lym-
phocytes and monocytes.
c. GCF contains leukocytes, 95% of which are neutrophils, the remainder being lym-
phocytes and monocytes.
d. Macrophages are a host defence factor whose mode of action is phagocytosis.
REF: Gingival crevicular fluid (GCF), p. 14
25. ANS: d
a. A high pH which occurs during the inflammation of gingivitis and periodontitis can
affect the proportions of bacteria, especially some of the putative periodontal
pathogens.
b. The flow of GCF removes non-adherent microbial cells.
c. Antibodies can inhibit the growth of oral microorganisms.
d. Correct. The oral cavity maintains a relatively constant temperature (35–36 ° C) which
provides a stable condition suitable for the growth of a wide range of microorganisms.
REF: Temperature, p. 14
26. ANS: c
a. The presence of root caries will not necessarily raise the temperature in a periodontal
pocket.
b. A rise in periodontal pocket temperature is not associated with a diminished flow of
GCF.
c. Correct. Periodontal pockets with active disease (inflammation) have a higher tempera-
ture (up to 39 ° C) compared with healthy sites.
d. Halitosis is not associated with a rise in temperature.
REF: Temperature, p. 14
27. ANS: d
a. Many microorganisms require a pH around neutrality for growth and are sensitive to
extremes of acid or alkali. Some anaerobes have a pH growth optimum just above neu-
trality, but cannot grow at high pH values.
b. Many microorganisms require a pH around neutrality for growth and are sensitive to
extremes of pH.
c. An environment high in oxygen is inhibitory to the growth of obligately anaerobic species
of microorganisms.
d. Correct. It is the degree of oxidation-reduction at a site that governs the survival and
relative growth of anaerobic microorganisms. Obligate anaerobes require a low redox
potential for growth.
REF: Redox potential/anaerobiosis, p. 15
28. ANS: a
a. Correct. Oxidation-reduction level is usually expressed as the Eh.
b. Oxygen is only one of the many interacting components influencing the Eh of a habitat
and its inhibitory action.
c. pH is a measurement of acidity and alkalinity.
d. Consumption ratio is not a recognised measure of oxygen reduction.
REF: Redox potential/anaerobiosis, p. 15
29. ANS: b
a. Gradients of oxygen concentration and Eh will exist in the oral cavity, and, therefore,
dental plaque is suitable for growth of bacteria with a range of oxygen tolerances.
b. Correct. Oral microorganisms are separated into aerobes and anaerobes on their ability
to grow in the presence or absence of oxygen, respectively.
c. Oxygen concentration is the main factor limiting the growth of anaerobic bacteria.
d. Bacteria that require carbon dioxide for growth are referred to as being capnophilic.
REF: Redox potential/anaerobiosis, pp. 14–15
30. ANS: b
a. Lactobacilli prefer to grow at a lower pH.
b. Correct. Lactobacilli prefer to grow at a lower pH.
c. Lactobacilli prefer to grow at a lower pH.
d. Lactobacilli prefer to grow at a lower pH.
REF: pH, Figure 2.4, p. 14

31. ANS: c
a. GCF contains novel nutrients, such as albumin and other host proteins and glycoproteins,
but does not influence growth on mucosal surfaces.
b. The persistence and diversity of the resident oral microflora is not due to the exogenous
factors in the diet but rather primarily to the metabolism endogenous nutrients provided
by the host.
c. Correct. The persistence and diversity of the resident oral microflora is due primarily to
the metabolism of the endogenous nutrients provided by the host.
d. The persistence and diversity of the resident oral microflora is due primarily to the
metabolism of the endogenous nutrients provided by the host.
32. ANS: c
a. Nitrate in green vegetables may have some influence on oral microflora.
b. Dairy products (milk, cheese) have some influence, but are not of major significance, on
the ecology of the mouth.
c. Correct. Despite the complexity of the diet, fermentable carbohydrates are the only class
of compound that markedly influences the ecology of the mouth.
d. Xylitol is a sugar substitute that has been added to some confectionery; it cannot be
metabolised by oral bacteria.
33. ANS: b
a. Hydrophilic and bacterial aggregating factors are chemical properties of salivary mucins
resulting in the formation of hydrophilic, viscoelastic gels, which function as protective
barriers over the oral epithelium.
b. Correct. An alternative terminology to non-specific and specific factors is innate immu-
nity and adaptive immunity.
c. An alternative terminology to non-specific and specific factors is innate immunity and
adaptive immunity.
d. Physiochemical and immunological barriers are part of the host defences associated with
oral mucosa.
REF: Host defences, p. 17
34. ANS: c
a. Microorganisms are unable to maintain themselves in saliva by cell division alone because
they are lost at an even faster rate by swallowing, not chewing.
b. Microorganisms are unable to maintain themselves in saliva by cell division alone because
they are lost at an even faster rate by swallowing, not GCF flow.
c. Correct. Microorganisms are unable to maintain themselves in saliva by cell division
alone because they are lost at an even faster rate by swallowing.
d. When saliva flow is blocked it can facilitate a shift in oral flora resulting in overgrowth
by Gram negative species but does not affect the inability of microorganisms to maintain
themselves in saliva alone.

35. ANS: d
a. Defensins have a broad spectrum of antimicrobial activity, not just antifungal.
b. Defensins have a broad spectrum of antimicrobial activity.
c. Glycolysis by plaque bacteria can be inhibited by the salivary peroxidase enzyme system,
not defensins.
d. Correct. Defensins are a family of antibacterial peptides with a broad spectrum of anti-
bacterial, antifungal and antiviral activity.
36. ANS: c
a. Porphyromonas gingivalis prefers to grow at an alkaline pH.
b. Porphyromonas gingivalis prefers to grow at an alkaline pH.
c. Correct. Porphyromonas gingivalis prefers to grow at an alkaline pH.
d. Porphyromonas gingivalis prefers to grow at an alkaline pH.
REF: pH, Figure 2.4, pp. 14–16
37. ANS: a
a. Correct. Secretory IgA (sIgA) is the main immunoglobulin in saliva.
b. IgG is found in the highest concentration in GCF.
c. IgM is found in the highest concentration in GCF.
d. IgA is found in the highest concentration in GCF.
REF: Saliva, pp. 11–12, and GCF, pp. 12–14
38. ANS: c
a. The microflora of identical twins is more similar than that of fraternal twins.
b. The microflora of identical twins is more similar than that of fraternal twins.
c. Correct. The microflora of identical twins is more similar than that of fraternal twins,
suggesting some genetic influence.
d. The microflora of identical twins is more similar than that of fraternal twins.
REF: Host genetics, p. 21
39. ANS: c
a. Toothpastes contain detergents such as sodium lauryl sulphate as a foaming agent and
can lead to the reduction of salivary bacterial counts in vivo, but are not as potent as
chlorhexidine.
b. Some mouthrinses contain antimicrobial agents including plant extracts, but have not
proven to be as potent as chlorhexidine.
c. Correct. The most potent antimicrobial agent in mouthrinses to date is chlorhexidine.
d. Although fluoride does inhibit bacterial metabolism, present in most toothpastes and
some oral rinses, its primary benefit is in the reduction of dental caries.
REF: Antimicrobial agents and inhibitors, p. 21

40. ANS: b
a. Antibiotics taken systemically or orally for problems at other sites in the body may cause,
after even a few hours, salivary microflora to be suppressed, which permits overgrowth
by yeasts.
b. Correct. Antibiotics taken systemically or orally for problems at other sites in the body
may cause, after even a few hours, salivary microflora to be suppressed, which permits
overgrowth by yeasts and/or the emergence of antibiotic-resistant bacteria.
c. Antibiotics given systemically or orally for problems at other sites in the body do not
cause the development of acid-tolerating organisms.
d. Histatins are a family of histidine-rich basic peptides found in human parotid and
submandibular/sublingual gland saliva. Antibiotics taken systemically or orally for prob-
lems at other sites in the body may cause, after even a few hours, salivary microflora to
be suppressed permitting overgrowth by yeasts and/or the emergence of antibiotic-
resistant bacteria.
REF: Antimicrobial agents and inhibitors, pp. 21–22

C H A P T E R 3
The Resident Oral Microflora
Multiple Choice
1. In biofilms such as dental plaque, which of the following parameters forms gradients of
ecological significance and markedly affect the distribution of bacteria?
a. Oxygen tension, pH and other factors.
b. Salivary peptides.
c. Temperature.
d. Calcium.
2. Which of the following protozoa are found in the mouth?

a. Paramecium.
b. Trichomonas tenax.
c. Entamoeba histolytica.
d. Giardia lamblia.
3. Classification of microorganisms is the process of which of the following?

a. Grouping microorganisms logically based on their similarities and differences.
b. Giving microorganisms a name.
c. Developing an identification scheme.
d. Describing the colonial appearance of a bacterial strain.
4. Early classification schemes relied heavily on which of the following?

a. Antigen characteristics.
b. Shape of cell.
c. Pattern of fermentation of simple sugars.
d. Morphological and simple physiological criteria.
5. What does chemotaxonomy not rely on in providing a broader analysis of the more complex
components of the cell?
a. Chemical composition of cell wall.
b. Composition of membrane lipids.
c. Whole cell protein profiles.
d. Pattern of fermentation of simple sugars.
6. The species of oral streptococci isolated from humans includes which of the following from
the mutans-group?
a. S. constellatus.
b. S. salivarius.
c. S. sobrinus.
d. S. gordonii.
20
3—The Resident Oral Microflora 21
7. Which of the following is a common national collection for supplying authenticated micro-
organisms for research purposes?
a. American Type Culture Collection.
b. European Collection of Culture Types.
c. Asian Collection Culture Collection.
d. Universal Type Culture Collection.
8. Using the culture-independent molecular approach, which of the following comprises one
of the main stages in determining the microbial composition of oral microflora samples?
a. DNA extraction.
b. Colony counts.
c. Dispersion and dilution.
d. Incubation.
9. Of the following, which is considered a disadvantage to using a culture approach to deter-

mine oral microbial composition?
a. Sensitivity testing is not possible.
b. It is semi-quantitative.
c. It is labour-intensive.
d. It is quantitative.
10. Of the following identification schemes, which one represents the microbial characteristic
of carbohydrate fermentation?
a. Acid or gas production.
b. Amino acid composition.
c. Pigment, haemolysis, shape and size.
d. Ammonia production.
11. Bacterial identification processes have been revolutionised in recent years by the advent of
a. Chemotaxonomy.
b. Determining the genetic relatedness among strains.
c. Molecular approaches.
d. Confocal microscopy.
12. Which of the following classification represents a collection of strains?

a. Subspecies.
b. Type strain.
c. Species.
d. Biovars.
13. Strains of Streptococcus salivarius produce large quantities of which exopolymer from sucrose?
a. Heteropolysaccharide.
b. Fructan (inulin-structure).
c. Fructan (levan structure).
d. Glycogen.
22 3—The Resident Oral Microflora
14. Bacteria that are dependant for their growth on carbon dioxide are referred to as which of
the following?
a. Obligately anaerobic.
b. Facultatively anaerobic.
c. Aerobic.
d. Capnophilic.
15. Which of the following has been isolated from all sites in the mouth?
a. Staphylococci.
b. S. pyogenes.
c. S. criceti.
d. Streptococci.
16. Which of the following is the reason for a great interest in mutans streptococci?
a. The role it plays in gingivitis.
b. The role it plays in periodontitis.
c. The role it plays in dental caries.
d. The role it plays in necrotising ulcerative gingivitis (NUG).
17. The name of mutans streptococci is derived from which of the following facts?
a. The cells possess cell wall carbohydrate.
b. Mutans streptococci cells can lose their coccal morphology.
c. Evidence of a serotype of carbohydrate antigens.
d. They can be experimentally induced and transmitted in animals.
18. Mutans streptococci are recovered almost exclusively from which of the following oral sur-
faces of the mouth?
a. Tongue.
b. Cheek.
c. Teeth.
d. Palate.
19. Which of the following is the most commonly isolated species of mutans streptococci?
a. S. mutans.
b. S. sobrinus.
c. S. criceti.
d. S. anginosus.
20. Which of the following is made by mutans streptococci and is associated with plaque
maturation?
a. Ammonia.
b. Glucan and fructan.
c. Lactate.
d. Neuraminidase.
21. Which of the following is a bacterium that is capnophilic?

a. Capnocytophaga gingivalis.
b. Porphyromonas gingivalis.
c. Fusobacterium nucleatum.
d. Veillonella atypica.
22. Of the following, which is isolated only rarely from diseased sites and is not considered a
significant opportunistic pathogen?
a. Streptococcus salivarius.
b. Streptococcus mutans.
c. Actinomyces israelii.
d. Filifacter alocis.
23. Which of the following species of Gram positive cocci is isolated mainly from the vestibular
mucosa of the human mouth?
a. S. salivarius.
b. S. gordonii.
c. S. sanguinis.
d. S. vestibularis.
24. Which of the following bacteria is an important cause of serious, purulent disease in humans,
including maxillo-facial infections?
a. S. sanguinis.
b. S. intermedius.
c. S. gordonii.
d. S. salivarius.
25. Which of the following bacteria is not routinely found in the mouths of healthy
individuals?
a. S. pyogenes.
b. S. salivarius.
c. S. mitis.
d. S. oraliss.
26. Which of the following Gram positive coccus is generally found in the oral cavity?
a. Actinomyces.
b. Anaeroglobus.
c. Streptococcus.
d. Neisseria.
27. Which of the following species forms a major portion of the microflora, particularly at
approximal sites and the gingival crevice?
a. Actinomyces israelii.
b. Actinomuces meyeri.
c. Actinomycesnaeslundii.
d. Actinomyces radicidentis.
28. Which of the following species produces colonies with a brown or black pigment on blood
agar?
a. Aggregatibacterium actinomycetemcomitans.
c. Prevotella oralis.
d. Eikenella corrodens.
29. Which of the following bacteria can increase in prevalence in advanced caries of both enamel
and root surfaces?
a. Lactobacillus species.
c. Parascardovia denticolens.
d. Rothia dentocariosa.
30. Cariogenic potential can be determined by estimating the numbers of which of the following
organisms?
a. Obligately anaerobic Gram negative rods.
b. Streptococcus anginosus group.
c. E. faecalis.
d. Lactobacilli.
31. An increased level of lactobacilli correlates to which of the following?

a. Poor oral hygiene.
b. An increase in carbohydrate consumption.
c. General health.
d. Increased intake of probiotics in dairy products.
32. Which of the following is an aerobic or facultative anaerobic Gram negative coccus that can
be isolated in low numbers from most sites in the oral cavity?
a. Eikenella corrodens.
b. Neisseria subflava.
c. Veillonella parvula.
d. Capnocytophaga gingivalis.
33. Of the following, which is among the earliest colonisers of teeth, making an important
contribution to initial plaque formation?
a. Veillonella parvula.
b. Eikenella corrodens.
c. Capnocytophagagingivalis.
d. Neisseria species.
34. The periodontal pathogen implicated in a particularly aggressive form of periodontal disease
in adolescents is which of the following?
a. Fusobacterium nucleatum.
b. Capnocytophaga gingivalis.
c. Aggregatibacter actinomycetemcomitans.
d. Eikenella corrodens.
35. Oral spirochaetes fall within which genus?

a. Bacteroides.
b. Centipeda.
c. Treponema.
d. Selenomonas.
36. Which of the following comprises a large proportion of the cultivable Gram negative micro-
flora found in subgingival dental plaque?
a. Filofactor alocis.
b. Eubacterium species.
c. Prevotella species.
d. Haemophilus species.
37. Which of the following statement about oral spirochaetes is false?

a. Oral spirochaetes possess periplasmic flagella.
b. The numbers of oral spirochaetes are raised in advanced periodontal diseases.
c. Culture-independent techniques have helped to determine the diversity of oral
spirochaetes.
d. The majority of oral spirochaetes can be cultured in the laboratory using advanced
anaerobic techniques.
38. A Gram negative anaerobic bacterium commonly found in infected root canals is which of
the following?
a. Porphyromonas catoniae.
c. Porphyromonas endodontalis.
d. Prevotella intermedia.
39. The sulphate-reducing bacteria such as methanogens contribute to which of the

following?
a. Caries.
b. Mouth odour.
c. Endodontic infections.
d. Necrotising ulcerative periodontitis.
40. Veillonella is an anaerobic Gram negative coccus that plays an important role in dental plaque
by which of the following actions?
a. Degrading collagen.
b. Producing hydrogen sulphide.
c. Penetrating underlying tissues.
d. Converting lactate to weaker acids.
41. Of the following, which represents the approximate percentage of organisms in plaque that
can be cultured in pure culture in the laboratory?
a. 80%.
b. 50%.
c. 25%.
d. 65%.
42. The largest proportion of the fungal microflora in the human mouth is made up of which
of the following?
a. Candida glabrata.
b. Candida albicans.
c. Candida krusei.
d. Candida tropicalis.
43. Which of the following is the most common site of oral isolation for Candida?
a. Saliva.
b. Dorsum of the tongue.
c. Intra-oral devices such as dentures.
d. Plaque.
44. Bacteria belonging to the genus Mycoplasma are primarily characterised by which of the
following traits?
a. The fusiform shape of the cell.
b. Their very large size.
c. Their fast growth.
d. The absence of a cell wall.
45. The virus most frequently encountered in saliva and the orofacial area is which of the
following?
a. Human papilloma (HPV).
b. Herpes simplex type 1.
c. Cytomegalovirus.
d. Coxsackie.
Feedback
1. ANS: a
a. Correct. In biofilms such as dental plaque, gradients develop in parameters of ecological
significance, such as oxygen tension and pH.
b. Salivary peptides do not develop gradients in biofilms that markedly affect the distribu-
tion of microorganisms.
c. Temperature might vary slightly, but would not have a marked effect on the distribution
of microorganisms in the biofilm.
d. Gradients in calcium might develop within the biofilm, but this would not markedly
affect the distribution of microorganisms in the biofilm.
REF: The resident oral microflora (introduction), p. 24
2. ANS: b
a. Paramecium is an aquatic protoan.
b. Correct. T. tenax can be found in the mouth.
c. E. histolytica causes amoebic dysentery.
d. G. lamblia causes giardiasis.
REF: Protozoa, p. 42
3. ANS: a
a. Correct. Classification involves the grouping of microorganisms in a logical manner
based on their similarities and differences.
b. The naming of a microorganism (nomenclature) follows the accurate classification of strains.
c. Identification schemes are developed once there is a robust classification system in place.
d. Describing the morphology of colonies is only part of classification and identification
schemes.
REF: Principles of microbial classification, pp. 25–27

4. ANS: d
a. Current characteristics used in microbial classification and identification schemes include
antigen characteristics.
b. Early classification schemes relied on morphological criteria, such as the shape of the
cell, but also needed staining profiles and other physiological criteria.
c. Early classification schemes relied on simple physiological criteria, such as fermentation
of simple sugars, but also needed staining profiles and simple morphological criteria.
d. Correct. Early classification schemes relied heavily on both morphological and simple
physiological criteria.
REF: The resident oral microflora (introduction), p. 25
5. ANS: d
a. Chemotaxonomy has led to major improvements in classification schemes based on
chemical composition of the cell wall or whole cell protein profiles.
b. Classification of membrane lipids was part of what led to major improvements in clas-
sification schemes.
c. Classification of the whole cell protein profiles was part of what led to major improve-
ments in classification schemes.
d. Correct. Chemotaxonomy, in which there is a broader analysis of more complex com-
ponents of the cell such as the chemical composition of the cell wall or whole cell protein
profiles, led to major improvements in classification schemes.
REF: Principles of microbial classification, pp. 25–26
6. ANS: c
a. S. constellatus is from the anginosus-group.
b. S. salivarius is from the salivarius-group.
c. Correct. S. mutans, S. sobrinus, S. critceti and S. ratti are from the mutans-group.
d. S. gordonii is from the mitis-group.
REF: Principles of microbial classification, Table 3.3, p. 26
7. ANS: a
a. Correct. Type stains are held in national collections such as the American Type Culture
Collection or the National Collection of Type Cultures.
b. The European Collection of Culture Types is not a recognised collection for microorganisms.
c. Asian Collection Culture Collection is not a recognised type collection.
d. Universal Type Culture Collection is not a recognised type collection.
REF: Principles of microbial classification, p. 27
8. ANS: a
a. Correct. DNA extraction is one stage in the determination of microbial composition of
microflora samples from the mouth using the molecular approach.
b. Colony counts are one stage in the determination of microbial composition of microflora
samples from the mouth using the culture approach.
c. Dispersion and dilution is one of the stages in culturing oral microorganisms.
d. Incubation is one of the stages in culturing oral microorganisms.
REF: Principles of microbial classification, p. 27, Figure 3.2

9. ANS: c
a. Antibiotic sensitivity testing is considered a positive aspect of the culture approach to
determining the composition of a sample of the oral microflora.
b. The culture approach is both semi-quantitative and quantitative.
c. Correct. The labour-intensive aspect of the culture approach to determining the com-
position of a sample of the oral microflora is considered a disadvantage.
d. The quantitative aspect of the culture approach to determining the composition of a
sample of the oral microflora is considered an advantage.
REF: Principles of microbial classification, p. 27, Figure 3.2
10. ANS: a
a. Correct. Acid or gas production is an example of the characteristic of carbohydrate
fermentation.
b. Amino acid composition is an example of the characteristic of peptidoglycan.
c. Pigment, haemolysis, shape and size are examples of the characteristic of colonial
appearance.
d. Ammonia production is an example of the characteristic of amino acid hydrolysis.
REF: Principles of microbial classification, p. 25, Table 3.2
11. ANS: c
a. Chemotaxonomy is the broad analysis of the complex components of the cell and was a
major advance many years ago.
b. Contemporary classification schemes are based more on determining the genetic related-
ness among strains, but are not a revolutionary advent.
c. Correct. Molecular approaches have revolutionised our understanding of the complexity
and diversity of the resident microflora. These approaches also permit the identification
of bacteria that cannot be cultured at present.
d. Confocal microscopy has revolutionised our understanding of the structure and architec-
ture of biofilms, but is less relevant to bacterial identification.
REF: Principles of microbial classification, p. 26
12. ANS: c
a. A species may be divided into subspecies if minor but consistent phenotypic variations
can be recognised, but does not represent a collection of strains.
b. Once a species has been recognised, then a type strain is nominated that has properties
representative of the species.
c. Correct. A species represents a collection of strains that share many features in common,
which differ considerably from other strains.
d. Strains with a special biochemical or physiological property are termed biovars, but do
not represent a collection of strains.
REF: Principles of microbial classification, pp. 26–27, Table 3.3

13. ANS: c
a. S. salivarius process large amounts of a levan from sucrose, which contributes to its large
mucoid colonies on sucrose-containing agar.
b. S. salivarius process large amounts of a levan from sucrose, which contributes to its large
mucoid colonies on sucrose-containing agar.
c. Correct. S. salivarius process large amounts of a levan from sucrose, which contributes
to its large mucoid colonies on sucrose-containing agar.
d. Glycogen is an intracellular polymer, not an exopolymer.
REF: Salivarius group, p. 32
14. ANS: d
a. Obligate anaerobes require a more complex gas mixture, including hydrogen, nitrogen
and carbon dioxide.
b. Facultatively anaerobic bacteria can grow in the presence or absence of carbon dioxide
and other gases.
c. Aerobic bacteria need oxygen for growth.
d. Correct. Bacteria that are dependant on carbon dioxide are termed ‘capnophilic’.
REF: Gram negative rods, p. 36 [see also p. 14]
15. ANS: d
a. Staphylococci are not commonly isolated in large numbers from the oral cavity.
b. S. pyogenes is not usually isolated from the mouth of healthy individuals.
c. S. criceti is recovered only rarely from humans.
d. Correct. Streptococci have been isolated from all sites in the mouth and comprise a large
proportion of the resident cultivable oral microflora.
REF: Gram positive cocci: streptococcus, p. 30
16. ANS: c
a. Gingivitis is an inflammatory response to a non-specific proliferation of the normal
microflora residing in the gingival crevice due to poor oral hygiene.
b. Periodontitis is caused by a microflora with a predominately anaerobic nature.
c. Correct. There is a great interest in mutans streptococci because of their role in the
aetiology of dental caries.
d. NUG is the manifestation of underlying systemic problems and is not associated with
mutans streptococci.
REF: Difficulties arising from recent advances in microbial classification, p. 30

17. ANS: b
a. Mutans streptococci possess cell wall carbohydrate antigens, lipoteichoic acid, lipopro-
teins and cell wall or cell wall-associated proteins. The name of this species, however,
derives from the fact that cells can lose their coccal morphology and often appear as short
rods or as cocco-bacilli.
b. Correct. The name of this species derives from the fact that cells can lose their coccal
morphology and often appear as short rods or as cocco-bacilli.
c. Serotypes have been recognised (a–h and k) based on the serological specificity of car-
bohydrate antigens located in the cell wall. The name of this species, however, derives
from the fact that cells can lose their coccal morphology and often appear as short rods
or as cocco-bacilli.
d. Little attention was paid to this species until the 1960s when it was demonstrated that
caries could be experimentally induced and transmitted in animals with strains resembling
S. mutans.
REF: Mutans-group (mutans streptococci), pp. 30–32
18. ANS: c
a. The tongue harbours many bacterial species that play a role in the development of hali-
tosis; mutans streptococci are recovered almost exclusively from non-shedding tooth
surfaces.
b. The cheek is not a site normally colonised by mutans streptococci.
c. Correct. Mutans streptococci are recovered almost exclusively from hard non-shedding
surfaces in the mouth, such as teeth.
d. The palate contains keratinised as well as non-keratinised stratified squamous epithelium
which may influence the intra-oral distribution of some microorganisms, but is not the
primary site of mutan streptococci colonisation.
REF: Gram positive cocci, pp. 30, 31
19. ANS: a
a. Correct. S. mutans is the most commonly isolated species of mutans streptococci.
b. S. sobrinus is recovered from dental plaque, but less frequently than S. mutans.
c. S. criceti is rarely recovered from humans.
d. S. anginosus is derived from purulent infections from a wide range of sites and is not a
member of the mutans streptococcus group.
REF: Gram positive cocci, p. 31
20. ANS: b
a. Mutans streptococci cannot generate ammonia from arginine.
b. Correct. Mutans streptococci make extracellular soluble and insoluble extracellular
polysaccharides (glucan, mutan and fructan) from sucrose that are associated with plaque
maturation.
c. Although lactate is an acidic fermentation product that is produced by mutans strepto-
cocci from dietary sugars, it is not associated with plaque maturation.
d. Mutans streptococci do not produce neuraminidase (an enzyme that removes sialic acid
from oligosaccharide side chains of salivary mucins).

21. ANS: a
a. Correct. The genus Capnocytophaga is capnophilic, i.e. is dependant for growth on
carbon dioxide.
b. P. gingivalis is obligately anaerobic.
c. F. nucleatum is obligately anaerobic.
d. V. atypica is obligately anaerobic.
REF: Gram negative cocci, Gram negative rods, p. 36
22. ANS: a
a. Correct. S. salivarius is isolated only rarely from diseased sites and is not considered a
significant opportunistic pathogen.
b. S. mutansi is associated with bacterial endocarditis and dental caries.
c. A. israelii is associated with actinomycosis.
d. F. alocis has been isolated from endodontic infections.
23. ANS: d
a. S. salivarius is commonly isolated from most areas of the mouth, although they most
often colonise mucosal surfaces, especially the tongue.
b. S. gordonii is an early coloniser of the tooth surface.
c. S. sanguinis is an early coloniser of the tooth surface.
d. Correct. S. vestibularis is isolated mainly from the vestibular mucosa of the human mouth.
24. ANS: b
a. S. sanguinis is a normal inhabitant of the healthy human mouth.
b. Correct. S. intermedius is readily isolated from dental plaque and from mucosal surfaces
and is an important cause of serious, purulent disease in humans, including maxillo-facial
infections.
c. S. gordonii is one of the initial colonisers of the periodontal environment; generally harm-
less, it can cause endocarditis upon gaining systemic access.
d. S. salivarius colonise the mouth and upper respiratory tract of humans a few hours after
birth, making further exposure to the bacteria harmless in most circumstances.
25. ANS: a
a. Correct. S. pyogenes is not usually isolated from the mouth of healthy individuals.
b. S. salivarius is routinely found in the mouth of healthy individuals.
c. Two of the most common streptococcal species in the mouth are S. mitis and S. oralis.
d. S. oraliss is one of the major early colonisers of dental surfaces in the human oral cavity.

26. ANS: c
a. Actinomyces is a Gram positive rod.
b. Anaeroglobus is a Gram negative coccus.
c. Correct. Streptococcus is a Gram positive coccus found in the oral cavity.
d. Neisseria is a Gram negative coccus.
27. ANS: c
a. Actinomyces israelii can act as an opportunistic pathogen causing a chronic inflammatory
condition called actinomycosis, but are not a major portion of the microflora.
b. A. meyeri has been reported occasionally and in low numbers from the gingival crevice in
health and disease.
c. Correct. Actinomyces naeslundii forms a major portion of the microflora of dental plaque,
particularly at approximal sites and the gingival crevice.
d. A. radicidentis has been isolated from endodontic infections.
REF: Gram positive rods and filaments, p. 34
28. ANS: b
a. A. actinomycetemcomitans does not generate brown or black colonies.
b. Correct. P. gingivalis produces characteristically brown/black colonies on blood agar.
c. While some Prevotella species produce pigmented colonies, P. oralis is non-pigmenting.
d. E. corrodens does not produce colonies with a brown/black pigment.
REF: Obligately anaerobic genera, Figure 3.7, pp. 37–39
29. ANS: a
a. Correct. Although lactobacilli usually comprise less than 1% of the total cultivable
microflora in the mouth, their proportions and prevalence increase in advanced caries
lesions.
b. Porphyromonas gingivalis is associated with advanced periodontal disease.
c. The role of Parascardovia denticolens (formerly B. denticolens) in the mouth is yet to be
determined, although they are regularly isolated from dental plaque.
d. Rothia dentocariosa is regularly isolated from dental plaque.
30. ANS: d
a. Obligately anaerobic Gram negative rods are implicated with periodontal diseases.
b. Representative species of the anginosus-group are readily isolated from dental plaque and
from mucosal surfaces and are an important cause of serious, purulent disease in humans,
but are not a predictor of cariogenic potential.
c. E. faecalis has been specifically associated with endodontic failures but is not generally
associated with dental caries.
d. Correct. Tests have been designed to provide an indication of the cariogenic potential
of a patient’s mouth by estimating the numbers of lactobacilli in a patient’s saliva.

31. ANS: b
a. Poor oral hygiene correlates a shift from the streptococci-dominated plaque of gingival
health to one in which Actinomyces spp., capnophilic, and obligately anaerobic Gram
negative bacteria predominate.
b. Correct. Increased levels of lactobacilli correlate closely with the intake of dietary
carbohydrate.
c. Changes in general health and the treatment of disease can alter the composition of the
oral microflora; increased lactobacilli levels are not among them.
d. Lactobacill are used as a probiotic, but their use does not correlate with oral colonisation
by lactobacilli.
32. ANS: b
a. E. corrodens is a facultative anaerobic Gram negative rod implicated in periodontal
disease.
b. Correct. Neisseria are Gram negative aerobic or facultative anaerobic cocci that are iso-
lated in low numbers from most sites in the oral cavity.
c. V. parvula is an anaerobic Gram negative coccus.
d. C. gingivalis is a Gram negative rod found in subgingival plaque.
REF: Gram negative cocci, p. 36
33. ANS: d
a. Veillonella are strictly anaerobic Gram negative cocci playing an important role in the
ecology of dental plaque and in the aetiology of dental caries but are not early
colonisers.
b. Strains of E. corrodens have been isolated from a range of oral infections including endo-
carditis and abscesses, and have been implicated in periodontal disease but are not early
colonisers.
c. Capnocytophaga is an opportunistic pathogen, isolated from a number of infections in
immunocompromised patients, and is not an early coloniser of dental plaque.
d. Correct. Neisseria species are among the earliest colonisers of teeth, and make an impor-
tant contribution to plaque formation, e.g. by consuming oxygen and making conditions
suitable for the growth of anaerobic bacteria.
REF: Gram negative cocci, p. 36
34. ANS: c
a. F. nucleatum makes an important contribution to plaque formation, but is not strongly
implicated in aggressive forms of periodontal disease.
b. C. gingivalis is an opportunistic pathogen but is not strongly implicated in aggressive
forms of periodontal disease.
c. Correct. A. actinomycetemcomitans has been implicated in a particularly aggressive form
of periodontal disease in adolescents.
d. E. corrodens has not been implicated in aggressive forms of periodontal disease.
REF: Gram negative rods, p. 36

35. ANS: c
a. Oral spirochaetes fall within the genus Treponema.
b. Oral spirochaetes fall within the genus Treponema.
c. Correct. Oral spirochaetes fall within the genus Treponema.
d. Oral spirochaetes fall within the genus Treponema.
REF: Obligately anaerobic genera, pp. 37–40
36. ANS: c
a. F. alocis is a Gram positive rod.
b. Eubacterium species are Gram positive rods.
c. Correct. Prevotella species are obligately anaerobic Gram negative rods which comprise
a large proportion of the microflora found in subgingival dental plaque.
d. Haemophilus species are Gram negative facultative anaerobic rods, but they are not
particularly associated with subgingival dental plaque.
REF: Obligatory anaerobic genera, p. 37
37. ANS: d
a. Oral spirochaetes do possess periplasmic flagella.
b. The numbers of oral spirochaetes do increase in advanced periodontal diseases.
c. The diversity of the oral spirochaetes has been determined using culture-independent
molecular techniques.
d. Correct. Most oral spirochaetes still cannot be cultured in the laboratory, even with the
use of advanced anaerobic techniques.
REF: Obligatory anaerobic genera, pp. 39–40
38. ANS: c
a. P. catoniae is found mainly at healthy sites or in shallow pockets.
b. P. gingivalis is associated more with advanced periodontal disease.
c. Correct. P. endodontalis is commonly found in infected root canals.
d. P. intermedia has been recovered mainly from periodontal pockets.
39. ANS: b
a. S. mutans is the primary cause of caries.
b. Correct. Sulphate-reducing organisms, such as methanogens, produce hydrogen sulphide
which can contribute to mouth odour.
c. P. endodontalis and P. dentalis are found almost exclusively in infected root canals and
abscesses of endodontic origin.
d. Sulphate-reducing bacteria are not implicated in necrotising ulcerative periodontitis.

40. ANS: d
a. T. denticola, not Veillonella, can degrade collagen and gelatine.
b. Sulphate-reducing organisms, such as methanogens, produce hydrogen sulphide which
can contribute to mouth odour.
c. Veillonella do not penetrate into underlying tissues.
d. Correct. Veillonella are anaerobic Gram negative cocci that play an important role in
dental plaque by converting lactate to weaker acids.
41. ANS: b
a. At present, only about 50% of the organisms in plaque can be isolated in pure culture in
the laboratory.
b. Correct. At present, only about 50% of the organisms in plaque can be isolated in pure
culture in the laboratory.
c. At present, only about 50% of the organisms in plaque can be isolated in pure culture in
the laboratory.
d. At present, only about 50% of the organisms in plaque can be isolated in pure culture in
the laboratory.
REF: Chapter summary, p. 42
42. ANS: b
a. Several yeasts, including C. glabrata, have been isolated from the human mouth in small
quantity.
b. Correct. The largest proportion of the fungal microflora in the human mouth is made
up of C. albicans.
c. Several yeasts, including C. glabrata, have been isolated from the human mouth in small
quantity.
d. Several yeasts, including C. glabrata, have been isolated from the human mouth in small
quantity.
REF: Fungi, p. 40
43. ANS: b
a. Saliva is the vehicle for the transmission of Candida spp. to other areas of the body.
b. Correct. Candida is distributed evenly throughout the mouth but the most common site
of isolation is the dorsum of the tongue.
c. The isolation of Candida increases with the presence of intra-oral devices such as den-
tures, but the most common site of isolation is the dorsum of the tongue.
d. Plaque can also harbour Candida spp., but the exact proportion and significance of these
yeasts in health and disease is unclear.
REF: Fungi, p. 41
44. ANS: d
a. Mycoplasmas are pleomorphic; several cell shapes can occur, depending on the
environment.
b. Due to their small size (<1 mm; they are the smallest of all free growing cells) mycoplas-
mas are difficult to visualise by normal light microscopy.
c. Mycoplasma are notoriously slow growing bacteria and requires specialised microbiological
culture media.
d. Correct. Bacteria belonging to the genus Mycoplasma are primarily characterised through
the absence of a cell wall.
REF: Mycoplasma, p. 41
45. ANS: b
a. There are more than 100 types of HPV, a number of which have been isolated from the
oral cavity; however, the virus most frequently encountered in saliva and the orofacial
area is Herpes simplex type 1.
b. Correct. The virus most frequently encountered in saliva and the orofacial area is Herpes
simplex type 1.
c. Although the cytomegalovirus is present in most individuals, the virus most frequently
encountered in saliva and the orofacial area is Herpes simplex type 1.
d. Coxsackie virus A2, 4, 5, 6, 8, 9, 10 and 16 have all been detected in saliva and in the
oral epithelium and are most often associated with hand, foot and mouth disease or
herpangina. The virus most frequently encountered in saliva and the orofacial area is
Herpes simplex type 1.
REF: Viruses, p. 41
C H A P T E R 4
Acquisition, Adherence,
Distribution and Metabolism of the
Oral Microflora
Multiple Choice
1. Colonisation involves microbes passing from mother to child; this can be described as which
of the following?
a. Transient inoculation.
b. Passive inoculation.
c. Foetal inoculation.
d. Familial inoculation.
2. The developing foetus is in which type of environment?

a. Sterile.
b. Teeming with microbes.
c. Harbours beneficial bacteria only.
d. Contains pioneer organisms.
3. Which of the following has been implicated most consistently in the acquisition of and
subsequent colonisation by microbes in a newborn?
a. Lactobacilli in the birth canal.
b. Yeasts in the birth canal.
c. Saliva from the mother.
d. Saliva from the father.
4. Microbes initially transferred from mother to newborn baby include which of the
following?
b. Mutans streptococci.
c. Streptococcus salivarius.
d. Porphyromonas gingivalis.
37
38 4—Acquisition, Adherence, Distribution and Metabolism of the Oral Microflora
5. Based on the results of a clinical study involving infant-mother pairs, in which family
member would you expect the genotype of mutans streptococci to match the one found in
the child?
a. Mother.
b. Father.
c. Brothers and sisters.
6. The type of transmission of oral microbes from mother to child is which of the following?
a. Horizontal.
b. Vertical.
c. Pioneer.
d. Clonal.
7. A pioneer species is defined as which of the following?

a. The first microorganisms to colonise.
b. The first of a species to be named.
c. Organisms that survive desquamation.
d. Organisms that can withstand low Eh.
8. All of the following predominant organisms are present during the development of the
pioneer community except which of the following?
a. S. salivarius.
b. S. mitis.
c. S. gordonii.
d. S. oralis.
9. Which of the following activities enables a pioneer species to evade the effects of host
defence factors?
a. IgA1 protease activity.
b. Producing additional nutrients.
c. Exposing new receptor sites.
d. Changing the local pH.
10. As pioneer organisms mature, which of the following modifications provides an environment
suitable for colonisation by a succession of other organisms?
a. Lowering the redox potential.
b. Reducing the local pH.
c. Consuming the available nutrients.
d. Increasing the availability of oxygen.
11. Urea can be converted to which of the following?

a. Lactate.
b. Acetate, formate and ethanol.
c. Ammonia and carbon dioxide.
d. Hydrogen sulphide.
4—Acquisition, Adherence, Distribution and Metabolism of the Oral Microflora 39
12. During primary tooth eruption, which of the following groups of organisms undergo the
largest increase in diversity and isolation frequency?
a. Gram positive aerobic bacteria.
b. Gram negative aerobic bacteria.
c. Gram positive obligately anaerobic bacteria.
d. Gram negative obligately anaerobic bacteria.
13. Oral malodour is associated with high proteolytic activity; which of the following is not
associated with halitosis?
a. Hydrogen sulphide.
b. Methyl mercaptan.
c. Phosphoenolpyruvate.
d. Dimethyl sulphide.
14. Non-microbial factors are responsible for which of the following?

a. Allogenic succession.
b. Climax succession.
c. Pioneer microbial community.
d. Autogenic succession.
15. Of the following functions, which does the large number of clonal bacteria in resident human
microflora accomplish?
a. Increases pathogenicity.
b. Helps species evade the host defences.
c. Allows for a greater species diversity of the plaque community.
d. Ensures species survival.
16. The increase in the prevalence of spirochaetes and black-pigmented anaerobes during
puberty is attributed to which of the following?
a. An increase in saliva.
b. A decrease in oral hygiene.
c. Hormones entering the gingival crevice acting as novel nutrient sources.
d. A change in diet.
17. The stability of the microbial composition and proportion over time is defined by which of
the following terms?
a. Balanced ecology.
b. Microbial homeostasis.
c. Co-existing complement.
d. Microbial diversity.
18. Which of the following is not a direct effect of ageing on oral flora?
a. A change in salivary antibodies.
b. Medication.
c. Hormonal changes.
d. Altered physiology of the mucosa.
19. The incidence of C. albicans is not proportional to an increase in which of the following?
a. Age.
b. Medication.
c. Wearing a dental prosthesis.
d. Salivary flow.
20. Which of the following statements reflects the effect of ageing on the immune response?
a. Cell mediated immunity increases with age.
b. Cell mediated immunity decreases with age.
c. Activities of specific salivary IgM antibodies increase with age.
d. Activities of specific salivary IgG antibodies increase with age.
21. Which of the following factors is not linked to an increased incidence of Candida with ageing?
a. Changes to the physiology of the oral mucosa in old age.
b. Malnutrition and a lack of trace elements in the elderly.
c. Increased incidence of denture wearing in old age.
d. Smoking.
22. There are a number of challenges in determining the composition of the microbial communi-
ties of the mouth; among those difficulties are which of the following?
a. Removing them from the surface to which they are attached.
b. Removing them during the correct stage of the microbial cell cycle.
c. Sampling the freshest organisms.
d. Difficulties in enumerating the sample.
23. An adequate microbial sample is which of the following?

a. A large plaque sample pooled from different sites.
b. Twelve-hour sampling taken at 1-hour increments for lactobacilli activity.
c. A small sample from discrete sites.
d. Mostly from posterior teeth.
24. Molecular analysis of organisms to determine microbial community profile and diversity is
best accomplished with which of the following?
a. Fluorescent in situ hybridization (FISH).
b. Denaturing gradient gel electrophoresis (DGGE).
c. 16SrRNA.
d. DNA-DNA checkerboard.
25. Difficulties in culturing the microflora from periodontal pockets include which of the
following?
a. Obligate anaerobes lose viability when exposed to air.
b. Sample will be mixed with blood components.
c. Sample will be contaminated with food debris.
d. The sample population will include many facultatively anaerobic bacteria.
26. A more sophisticated method of sampling a periodontal pocket includes the use of which
of the following?
a. Periodontal probe.
b. Irrigation.
c. Paper points.
d. A broach flushed with gas.
27. Vortexing a plaque sample with glass beads facilitates which of the following?
a. Disruption of the clumping associated with the plaque biofilm.
b. Separation of Gram negative from Gram positive organisms.
c. Maintenance of a low redox potential to facilitate viability.
d. Dilution of the sample prior to plating.
28. At present, what percentage of residential oral microflora can be cultured in the laboratory?
a. 10%.
b. 35%.
c. 50%.
d. 75%.
29. An example of a culture medium designed to grow the maximum number of bacteria would
be which of the following?
a. Eosin methylene blue medium.
b. A selective agar.
c. Blood agar.
d. MacConkey agar.
30. Of the three assumptions of colony counting, which one may not be accurate?
a. Cells of the same microorganism produce colonies with an identical morphology.
b. Cells of different species produce distinct morphologies.
c. One colony arises from a single cell.
d. All three assumptions are completely accurate.
31. The first level in identification of a bacterium is which of the following?

a. Determine the acid-end product profile following sugar metabolism.
b. Determination of cell structure using electron microscopy.
c. Gram staining and light microscopy.
d. Chemical analysis of the cell wall.
32. Which of the following is not an enzyme involved in the scavenging of oxygen or other
reactive oxygen species by anaerobic bacteria?
a. Enolase.
b. Catalase.
c. Superoxide dismutase.
d. NADH oxidase.
33. A non-invasive microscopy method currently used to reconstruct the full three-dimensional
structure of a biofilm is which of the following?
a. Confocal microscopy.
b. Darkfield microscopy.
c. Light microscopy.
d. Scanning electron microscopy.
34. Inserting pieces of enamel into an intraoral prosthesis and removing it to study oral biofilms is
an example of which model of determining the composition of the resident oral microflora?
a. Enumeration and identification.
b. Molecular approach.
c. In vivo.
d. In situ.
http://dentalebooks.com
35. To simultaneously screen multiple clinical samples for 40 different preselected microbial
species, which of the following molecular approach would be selected?
a. 16S rRNA.
b. DGGE.
c. DNA-DNA hybridisation technique.
d. FISH.
36. Facultative anaerobic streptococci are the predominant group of bacteria found mostly on
which of the following oral surfaces?
a. Dental prostheses.
b. Approximal enamel surface.
c. Cheeks and lips.
37. The predominant group of organisms recovered from the palate of healthy individuals
belongs to which of the following bacterial genera?
a. Streptococcus.
b. Haemophilus.
c. Prevotella.
d. Veillonella.
38. Candida are most likely to be recovered from the palate of which of the following?
a. A smoker.
b. Under conditions causing xerostomia.
c. A denture wearer.
d. An HIV patient.
39. Which of the following oral surfaces supports the highest bacterial density?
a. Cheek.
b. Smooth enamel surfaces.
c. Tongue.
d. Palate.
40. Oral malodour is associated with which of the following groups of microorganisms?
a. S. salivarius, S. mitus, Rothia mucilaginosa.
b. Neisseria, Actinomyces, Prevotella.
c. Porphyromonas, Prevotella, Fusobacterium spp.
d. V. parvula, C. gingivalis, Granulicatella.
41. Which of the following is not true about saliva?

a. Saliva does not have its own resident bacteria.
b. Saliva tests for mutans streptococci and lactobacillus form the basis of caries risk
assessment.
c. Saliva contains approximately 106 bacteria/ml.
d. Bacterial multiplication cannot occur in saliva.
42. Many of the anaerobic bacteria isolated from the periodontal pocket have which of the fol-
lowing type of metabolism?
a. Saccharolytic.
b. Asaccharolytic and proteolytic.
c. Capnophilic.
d. Fermentative.
43. The bacterial load one would expect to find on mucosal surfaces is which of the
following?
a. High.
b. Low.
c. Similar to subgingival sites.
d. There is no bacterial load on mucosal surfaces.
44. The abilities of microbes to overcome the oral removal forces include which of the
following?
a. Pioneer colonisation.
b. Succession.
c. Specific adhesion.
d. Transportation and dispersion.
45. The final proportions of attached microorganisms are determined by tissue tropism and
a. The ability to maintain a low Eh.
b. The ability to withstand anoxia.
c. The ability to adhere strongly.
d. The ability to grow and compete successfully with neighbouring bacteria.
46. Bacteria such as Streptococcus mutans survive in a low pH environment in biofilms by which
of the following strategies?
a. Increase in the activity of their H+/ATPase enzyme.
b. Shift to a heterofermentative metabolism.
c. Metabolism of arginine to ammonia.
d. Raising the pH optima of glycolytic enzymes.
47. Which of the statements concerning pellicles on oral surfaces is not correct?
a. Pellicles form on all oral surfaces.
b. Pellicles are all identical in composition.
c. The pellicle that forms on epithelium is the mucus coat.
d. Pellicle formation occurs as soon as a clean surface is exposed to saliva.
48. Adhesins associated with surface structures on bacteria are called which of the following?
a. Acquired cementum pellicle.
b. Acquired pellicle.
c. Fibrils.
d. Mucus coat.
49. A specific adhesin found in most streptococci is which of the following?

a. Enolase.
b. Antigen I/II family of cell surface-anchored polypeptides.
c. Invertase.
d. Fimbriae.
50. The function of colonisation resistance is which of the following?

a. To provide receptors for adhesion.
b. To prevent attachment by exogenous microorganisms.
c. To produce inhibitory substances.
d. To provide essential endogenous nutrients.
51. Colonisation resistance can be perturbed by which of the following?

a. Metabolism of endogenous substrates.
b. Increase in the intake of fermentable carbohydrates.
c. Use of an alcohol-based oral rinse.
d. Long-term use of broad spectrum antibiotics.
52. The need for microflora to be biochemically flexible stems from which of the following?
a. The fluctuating conditions of nutrient supply (feast-famine).
b. A pathogenic relationship with the host.
c. A commensal relationship with the host.
d. Nutritional dependency on exogenous factors.
53. As a factor in carbohydrate metabolism, sucrose is used in all of the following ways except
for which of the following?
a. Broken down by amylases of salivary and bacterial origin.
b. Broken down by extracellular bacterial invertases.
c. Transported intact as a disaccharide.
d. Used extracellularly by glycosyltransferases.
54. The most significant high affinity system of transporting carbohydrates across the cytoplas-
mic membrane and into the bacterial cell by mutans streptococci is by which of the following
processes?
a. Phosphoenolpyruvate-mediated phosphotransferase (PEP-PTS).
b. Multiple sugar metabolism system (Msm).
c. Glucose permease.
d. Glucosyltransferases (GTF).
55. Under conditions of carbohydrate excess, in what way do bacteria reduce toxic intracellular
levels of glycolic intermediates?
a. By using a second transport system Msm.
b. By binding protein.
c. By forming glycogen.
d. Via PEP-PTS.
56. When and where are acetic, succinic, propionic, valeric, caproic and butyric acids found?
a. They are a product of protein catabolism.
b. They are acids found in human plaque sampled after overnight fasting.
c. They are metabolites found an hour after the ingestion of dairy compounds.
d. They are acids formed following the ingestion of high concentration of dietary sucrose.
57. S. mutans uses sucrose to produce which of the following glucose-containing

polymers?
a. Water-insoluble and soluble glucans.
b. Peptidoglycan.
c. Levan.
d. Inulin.
58. High odour producers have which of the following bacterial profiles?
a. Low bacterial load on the tongue, higher numbers of Gram negative aerobes.
b. High bacterial load on the tongue, low numbers of Gram positive anaerobes.
c. Higher bacterial load on the tongue, higher numbers of Gram negative anaerobes.
d. Low bacterial load on the tongue, higher numbers of Gram positive aerobes.
Feedback
1. ANS: b
a. Some microorganisms are acquired only transiently but this is not true
colonisation.
b. Correct. Microbes acquired from the mother is passive inoculation of the child.
c. Foetal inoculation is not a means of passing microbes from mother to child.
d. Familial inoculation is not a means of passing microbes from mother to child.
REF: Acquisition of resident oral microflora, p. 45
2. ANS: a
a. Correct. The womb is normally sterile.
b. The womb is normally sterile. Microbial acquisition happens after birth.
c. The womb is normally sterile. Microbial acquisition happens after birth.
d. Pioneer organisms arrive following birth.
3. ANS: c
a. Lactobacilli in the birth canal is transient, at best.
b. Yeast in the birth canal is transient, at best.
c. Correct. The acquisition of microbes by a newborn happens mainly through salivary
transfer from mother to child.
d. Microbes can occasionally be transferred to a newborn from other family members, but
it is mainly from the mother.
4. ANS: c
a. There is no evidence that E. corrodens can be transferred from mother to newborn; it
generally colonises later.
b. Mutans streptococci usually requite teeth to be present before they colonise.
c. Correct. S. salivarius and some other species are transferred from mother to newborn via
saliva.
d. P. gingivalis does not normally colonise the mouth until after tooth eruption.
5. ANS: a
a. Correct. In the majority of infant-mother pairs examined, the genotype of mutans
streptococci in the mother matched the one found in the child.
b. Little evidence of father-infant transmission of mutans streptococci was observed.
c. Strains of some bacteria can be acquired occasionally by young children from other family
members.
d. The genotypes of mutans streptococci found in children were generally identical to those
of their mothers.
6. ANS: b
a. Horizontal transmission occurs between spouses.
b. Correct. Transmission from mother to infant is vertical.
c. Pioneer is not a form of transmission but succession.
d. Clonal refers to a microbe’s origins, not a mode of transmission.
7. ANS: a
a. Correct. The first microorganisms to colonise are called pioneer species. Collectively they
make up the pioneer microbial community.
b. The first microorganisms to colonise are called pioneer species.
c. Desquamation is one of the physical environmental resistance factors limiting pioneer
community growth.
d. Eh (redox potential) is one of the local environmental factors limiting pioneer community
growth.
8. ANS: c
a. S. salivarius, S. mitis and S. oralis are the particular predominant cultivable organisms
present during the development of the pioneer community.
b. S. salivarius, S. mitis and S. oralis are the particular predominant cultivable organisms
c. Correct. S. gordonii is not a predominant streptococcus present during the initial pioneer
colonisation; it is more present several months after birth.
d. S. salivarius, S. mitis and S. oralis are the particular predominant cultivable organisms
REF: Pioneer community and microbial succession, pp. 46–47
9. ANS: a
a. Correct. Many of the pioneer species possess IgA1 protease activity, which may enable
producer organisms to evade the effects of this key host defence factor.
b. Producing additional nutrients addresses the way in which pioneer communities are able
to influence the pattern of microbial succession.
c. Exposing new receptor sites addresses the way in which pioneer communities are able to
influence the pattern of microbial succession.
d. Changing the local pH addresses the way in which pioneer communities are able to
influence the pattern of microbial succession.
10. ANS: a
a. Correct. Lowering the redox potential encourages bacterial succession, especially by
obligately anaerobic bacteria.
b. Reducing the local pH may reduce the number of pioneer species able to colonise.
c. Consuming additional nutrients may reduce the pattern of microbial succession.
d. Increasing oxygen levels would restrict the pattern of microbial succession, especially by
inhibiting the growth of obligate anaerobes.
11. ANS: c
a. Lactate is a product of carbohydrate metabolism.
b. Acetate, formate and ethanol are products of carbohydrate metabolism.
c. Correct. Urea can be converted by some oral bacteria to ammonia and carbon dioxide.
d. Hydrogen sulphide is a product of the metabolism of sulphur-containing compounds.
REF: Nitrogen metabolism, p. 69
12. ANS: d
a. Gram negative obligately anaerobic bacteria are isolated more commonly during primary
tooth eruption.
b. Gram negative obligately anaerobic bacteria are isolated more commonly during primary
tooth eruption.
c. Gram negative obligately anaerobic bacteria are isolated more commonly during primary
tooth eruption.
d. Correct. Gram negative obligately anaerobic bacteria are isolated more commonly, and
a greater diversity of species is recovered from around the gingival margin of the newly
erupted teeth.
13. ANS: c
a. Halitosis is associated with the production of volatile sulphur compounds such as hydro-
gen sulphide.
b. Halitosis is associated with the production of volatile sulphur compounds such as methyl
mercaptan.
c. Correct. Phosphoenolpyruvate is a glycolytic intermediate and not associated with
halitosis.
d. Halitosis is associated with the production of volatile sulphur compounds such as dime-
thyl sulphide.
REF: Oral malodour (halitosis), p. 71
14. ANS: a
a. Correct. Factors of non-microbial origin are responsible for an altered pattern of com-
munity development in allogenic succession. For example, tooth eruption significantly
alters the microbial succession of organisms, as will a newly inserted denture, removable
orthodontic appliance or an acrylic obturator.
b. A climax succession is a process in the development of a microbial community.
c. A pioneer microbial community is the collection of the earliest colonisers.
d. Autogenic succession is when community development is influenced by microbial factors;
for example, the increase is number and diversity of obligate anaerobes in biofilms is due
to the utilisation of oxygen by pioneer species.
REF: Allogenic and autogenic microbial succession, pp. 47–49
15. ANS: b
a. Relatively few clones are found within species of pathogenic bacteria, and a limited
number of these may be responsible for the majority of infections.
b. Correct. Resident human microflora generally display large numbers of clones, and this
may be a strategy to help such species evade the host defences.
c. Having a large number of clonal bacteria in resident human microflora does not address
species diversity.
d. Having a large number of clonal bacteria in resident human microflora does not alone
ensure species survival; the clonal aspect alone does not assure survival.
16. ANS: c
a. Hormones entering the gingival crevice acting as novel nutrient sources increase the
prevalence of spirochaetes and black-pigmented anaerobes during puberty.
b. Hormones entering the gingival crevice acting as novel nutrient sources increase the
c. Correct. Following tooth eruption, the isolation frequency of spirochaetes and black-
pigmented anaerobes increases. The increased prevalence of spirochaetes and black-
pigmented anaerobes during puberty might be due to hormones entering the gingival
crevice and acting as a novel nutrient source.
d. Hormones entering the gingival crevice acting as novel nutrient sources increase the
REF: Ageing and the oral microflora, p. 49
17. ANS: b
a. Balanced ecology speaks to the environment in which the microbial community lives, not
of its stability or lack thereof.
b. Correct. Microbial homoeostasis in adults occurs when the composition and proportions
of the resident oral microflora remain reasonably stable over time and coexist in relative
harmony with the host.
c. Co-existing complement is not a recognised term.
d. Microbial diversity may or may not be part of the stable pattern of a specific microbial com-
munity. It is a term that speaks to the composition and not to the state or status of the group.
18. ANS: b
a. A direct effect of ageing on oral flora includes a change in salivary antibodies.
b. Correct. Medication is an indirect effector of ageing on the oral microflora.
c. A direct effect of ageing on oral flora includes hormonal changes.
d. A direct effect of ageing on oral flora includes altered physiology of the mucosa.
19. ANS: d
a. The incidence of C. albicans increases with age.
b. The incidence of C. albicans increases with medication use.
c. The incidence of C. albicans increases with wearing a dental prosthesis.
d. Correct. The incidence of C. albicans does not increase with salivary flow.
20. ANS: b
a. Cell mediated immunity decreases with age.
b. Correct. Cell mediated immunity decreases with age.
c. Activities of specific IgM antibodies decrease in the elderly.
d. Activities of specific IgG antibodies decrease in the elderly.
21. ANS: d
a. The incidence of oral candidosis is more common in the elderly and this has been attrib-
uted not only to the increased likelihood of denture wearing but also to physiological
changes in the oral mucosa, malnutrition and trace element deficiencies.
b. The incidence of oral candidosis is more common in the elderly and this has been attrib-
c. The incidence of oral candidosis is more common in the elderly and this has been attrib-
d. Correct. Smoking has been shown to affect bacterial counts and is a significant risk factor
for periodontal diseases but is not specifically linked to oral candidosis.
22. ANS: a
a. Correct. There are a number of challenges when attempting to determine the composi-
tion of the microbial communities at sites in the mouth. These range from the basic
problem of removing the majority of the microorganisms from their habitat (many of
which are by necessity bound tenaciously to a surface or to each other, and the site may
be difficult to access) to their eventual identification.
b. The stage in the cell cycle of the microbes is not important to sample collection.
c. Sampling ‘old’ or ‘new’ plaque is not a particular challenge.
d. Enumerating the population sampled is part of the identification process.
REF: Methods of determining the composition of the resident oral microflora, Table 4.3,
pp. 50–51
23. ANS: c
a. Large plaque samples from different sites can be of little value because important site-
specific differences will be obscured.
b. Lactobacilli activity can be monitored; this is not a sample method but a protocol for
assessment of caries risk.
c. Correct. The microflora can vary in composition over relatively small distances. Therefore,
large plaque samples or a number of smaller pooled samples from different sites can be
of little value because important site-specific differences will be obscured. Consequently,
small samples from discrete sites are preferable.
d. Samples can be taken from any teeth; they should always be as small as is feasible from
discrete sites.
REF: Methods of determining the composition of the resident oral microflora, Figure 4.4,
pp. 50–51
24. ANS: b
a. FISH looks at community structure.
b. Correct. DGGE can be used for community profiling and estimating the diversity of
the microbial community.
c. 16SrRNA is used for gene amplification and microbial identification.
d. DNA-DNA checkerboard detects preselected microorganisms.
REF: Methods of determining the composition of the resident oral microflora, Figure 4.4,
pp. 50–51
25. ANS: a
a. Correct. High numbers of obligately anaerobic bacteria are found in the gingival crevice
and periodontal pocket, most of which will lose their viability if exposed to air.
b. The sample may or may not be mixed with blood components but it is not a difficulty
in the culturing process.
c. The presence of food debris will not impact the culture process.
d. Facultatively anaerobic bacteria are not difficult to grow in the laboratory.
REF: Methods of determining the composition of the resident oral microflora, Table 4.3, p.
50–52
26. ANS: d
a. A periodontal probe would not be an ideal collection instrument.
b. Irrigation is not a sophisticated collection method.
c. A common approach is to insert paper points into pockets but the number of firmly
adherent organisms removed from the root of the tooth will be small.
d. Correct. A particularly sophisticated method employs a broach kept withdrawn in a
cannula that is flushed constantly with oxygen-free nitrogen. After sampling at or near
the base of the pocket, the broach is retracted into the cannula and withdrawn.
REF: Methods of determining the composition of the resident oral microflora, p. 52
27. ANS: a
a. Correct. One of the most efficient methods ensuring a single layer of cells in a sample,
particularly for subgingival plaque, is to vortex samples with small, sterile glass beads,
ideally in a tube filled with inert gas.
b. Vortexing does not separate Gram negative from Gram positive organisms.
c. Specially designed transport fluids containing reducing agents, not vortexing, maintain a
low redox potential to help reduce the loss of viability of anaerobic organisms during
delivery to the laboratory.
d. Samples are diluted in the cultivation not dispersion process.
28. ANS: c
a. At present only about 50% of the resident oral microflora can be cultured in the
laboratory.
b. At present only about 50% of the resident oral microflora can be cultured in the
laboratory.
c. Correct. At present only about 50% of the resident oral microflora can be cultured in
the laboratory.
d. At present only about 50% of the resident oral microflora can be cultured in the
laboratory.
29. ANS: c
a. Eosin methylene blue contains dyes toxic for Gram positive bacteria and bile salts toxic
to Gram negative bacteria and is a selective and differential medium for coliforms.
b. A selective medium is designed to grow only a limited number of species.
c. Correct. Blood agar is an example of a culture medium designed to grow the maximum
number of bacteria.
d. MacConkey agar is a selective medium used to culture Gram negative enteric bacteria.
30. ANS: c
a. Generally, the assumption holds true that cells of the same microorganism produce colo-
nies with an identical morphology.
b. Generally, the assumption holds true that cells of different species produce distinct
morphologies.
c. Correct. Generally, these assumptions hold true except that most colonies inevitably arise
from small aggregates of cells, not a single cell; this emphasises the need for efficient
dispersion of samples.
d. Only the first two assumptions are generally accurate.
31. ANS: c
a. Some bacteria do require a more sophisticated approach such as the application of gas–
liquid chromatography to determine their acid end-products of metabolism; however, it
is not the first level in the enumeration and identification process.
b. Electron microscopy can be used later to determine the fine structure of a bacterial cell.
c. Correct. The first level of discrimination involves the Gram staining of subcultured colo-
nies. This provides evidence as to whether the organism is Gram positive or Gram nega-
tive and provides information on cell morphology.
d. Chemical analysis of the bacterial cell wall is a sophisticated approach applied to only
certain groups of micro-organisms.
32. ANS: a
a. Correct. Enolase is an enzyme involved in glycolysis.
b. Catalase is used to scavenge hydrogen peroxide by some bacteria.
c. Superoxide dismutase is used to scavenge oxygen radicals by some bacteria.
d. NADH oxidase is used to scavenge oxygen by some bacteria.
REF: Oxygen metabolism, p. 70.
33. ANS: a
a. Correct. Non-invasive techniques such as confocal laser scanning microscopy are cur-
rently used, with and without the use of specific probes (antibody or oligonucleotide), to
determine the true architecture of plaque and the location of selected bacteria within the
biofilm.
b. Darkfield microscopy has been used to quantify the numbers of motile bacteria (including
spirochaetes) directly in dental plaque (particularly from subgingival sites).
c. Light microscopy does not give a full 3-D structure of biofilms.
d. Electron microscopy requires samples to be processed before viewing which can distort
the structure of biofilms.
34. ANS: d
a. Enumeration and identification involves counting microbial colonies. The prosthesis is
an example of an in situ model to facilitate sampling.
b. A molecular approach is involved in examining samples. The prosthesis is an example of
an in situ model to facilitate sampling.
c. In vivo means within the living, e.g. using human or animal samples. A prosthesis would
more appropriately be named an in situ method, meaning ‘in the place’.
d. Correct. The prosthesis method of sampling would be an in situ model.
REF: Methods of determining the composition of the resident oral microflora, pp. 53–54
35. ANS: c
a. 16S rRNA gene sequences have enabled the recognition in clinical specimens of species
that are as yet unculturable in the laboratory.
b. DGGE is used to compare the diversity of oral microbial communities from different
sites in health and disease.
c. Correct. DNA-DNA hybridisation technique is used to simultaneously screen multiple
clinical samples for 40 different preselected microbial species.
d. FISH examines the community structure.
36. ANS: c
a. Dental prostheses will present with a host of intraoral microbes.
b. Approximal surfaces support a diverse microflora including many anaerobes.
c. Correct. Cheeks and lips house mostly facultative anaerobes, such as streptococci.
d. Gingival crevice provides a site which supports a diverse microflora, including obligate
anaerobes.
REF: Distribution of the resident oral microflora, Figure 4.5, pp. 54–55
37. ANS: a
a. Correct. The microflora of the normal palate can show large variations between subjects,
not only in the total colony forming units removed, but also in the proportions of the
individual species. The majority of the bacteria recovered are streptococci.
b. Haemophili and Gram negative anaerobes are also regularly recovered but at low levels.
c. The majority of the bacteria recovered are streptococci.
d. The majority of the bacteria recovered are streptococci.
REF: Distribution of the resident oral microflora, pp. 54–55
38. ANS: c
a. Smoking is not a direct contributing factor to the growth of Candida.
b. Xerostomia is not a contributing factor to Candida growth.
c. Correct. Candida are not regularly isolated from the normal palate except when dentures
are worn; in this situation, the mucosa of the palate can become infected with C. albicans.
d. Candida is an opportunistic organism found in HIV positive patients; however, the palate
is not a typical site for colonisation.
REF: Distribution of the resident oral microflora, p. 55
39. ANS: c
a. The dorsum of the tongue supports a higher bacterial density than other oral surfaces
such as the buccal mucosa.
b. The dorsum of the tongue supports a higher bacterial density than other oral surfaces
such as smooth surfaces on teeth.
c. Correct. The dorsum of the tongue with its highly papillated surface has a large surface
area and supports a higher bacterial density and a more diverse microflora than other oral
mucosal surfaces.
d. The palate has a low bacterial density.
REF: Distribution of the resident oral microflora, pp. 55–58
40. ANS: c
a. A higher bacterial load, especially of Gram negative anaerobes (including Porphyromonas,
Prevotella and Fusobacterium spp.), was isolated from the tongues of subjects with high
odour.
b. A higher bacterial load, especially of Gram negative anaerobes (including Porphyromonas,
odour.
c. Correct. Oral malodour is associated with the microflora of the tongue. A higher
bacterial load, especially of Gram negative anaerobes (including Porphyromonas,
odour.
d. A higher bacterial load, especially of Gram negative anaerobes (including Porphyromonas,
odour.
41. ANS: c
a. Although saliva contains up to 108 microorganisms/ml, it is not considered to have its
own resident microflora.
b. The level of mutans streptococci and/or lactobacilli has been used as an indicator of the
caries susceptibility of an individual, and kits for their culture are commercially
available.
c. Correct. Saliva contains about 108 bacteria/ml.
d. The normal rate of swallowing ensures that bacteria cannot be maintained in the mouth
by multiplication in saliva.
42. ANS: b
a. Saccharolytic metabolism involves the breakdown of carbohydrates.
b. Correct. Many of the anaerobic bacteria isolated from the periodontal pocket gain their
energy from the breakdown of host proteins, and this is referred to as being asaccharolytic
and proteolyic.
c. Capnophilic refers to the fact that some bacteria require carbon dioxide for
growth.
d. Fermentation involves the breakdown of carbohydrates.
REF: Nitrogen metabolism, p. 69
43. ANS: b
a. Due to desquamation, the bacterial load on mucosal surfaces is low.
b. Correct. Due to desquamation, the bacterial load on mucosal surfaces is low.
c. Subgingival surfaces have a high bacterial load.
d. All mucosal surfaces have low microbial loads.
44. ANS: c
a. Pioneer colonies are the first to colonise on tooth surfaces and not a characteristic of microbes.
b. Succession refers to the increase in complexity of the microbial community over time,
from single species to a diverse group of interacting microorganisms, and does not refer
to the ability to overcome removal forces.
c. Correct. For successful colonisation, microorganisms must first adhere to a surface and
then be able to multiply. In order to overcome the oral removal forces, microbes either
seek out habitats that offer protection (refuge) from the environment, or they deploy
specific adherence mechanisms. The distribution of many oral populations is related to
their ability to adhere to specific surfaces.
d. Transportation and dispersion do not impact the ability to withstand oral removal forces.
REF: Factors influencing the distribution of oral microorganisms, p. 59
45. ANS: d
a. The degree of anaerobiosis (redox potential; Eh) and nutrient availability will determine
whether the attached cells can grow at a site. The sites with the lowest Eh (and the highest
number of obligate anaerobes) are those associated with stagnant areas on the teeth.
b. In dental plaque, oxygen consumption by aerobic and facultatively anaerobic organisms
can create anoxic (oxygen-depleted) conditions which will also facilitate the growth of
obligate anaerobes.
c. The ability to adhere strongly is a factor in overcoming forces of oral removal.
d. Correct. The final proportions of attached microorganisms are determined by their
subsequent ability to grow and compete successfully with neighbouring species.
REF: Factors influencing the distribution of oral microorganisms, p. 59
46. ANS: a
a. Correct. Streptococcus mutans increases the activity of H+/ATPase system to remove
protons from inside the cell.
b. S. mutans shifts to a homofermentative metabolism.
c. S. mutans, unlike some other streptococci, cannot metabolise arginine.
d. S. mutans would lower the pH optima of glycolytic enzymes.
REF: Acid tolerance, p. 66
47. ANS: b
a. Pellicle forms on all oral surfaces, but is not identical.
b. Correct. The composition of the pellicle that forms on all oral surfaces is not identical.
c. The pellicle that forms on epithelium is the mucus coat.
d. Pellicle formation occurs as soon as a clean surface is exposed to saliva.
REF: Host and bacterial factors involved in adherence, p. 60
48. ANS: c
a. Pellicles contain host receptors, not bacterial adhesins.
b. Pellicles contain host receptors, not bacterial adhesins.
c. Correct. Often adhesins are associated with surface structures termed fibrils or fimbriae.
Fibrils are short and narrow while fimbriae have a measurable width (3–14 nm) and a
variable length up to 20 mm.
d. Mucus coat is an alternative term for the pellicle that forms on the epithelial surface.
REF: Host and bacterial factors involved in adherence, pp. 60–61
49. ANS: b
a. Enolase is an enzyme involved in glycolysis.
b. Correct. A significant adhesin is the antigen I/II family of cell surface-anchored polypep-
tides found in most oral streptococci.
c. Invertase is an enzyme involved in the metabolism of sucrose.
d. The presence of fimbriae greatly enhances the bacteria’s ability to attach to the host;
however, a specific adhesin found in most streptococci is the antigen I/II family of cell
surface-anchored polypeptides.
REF: Host and bacterial factors involved in adherence, p. 61
50. ANS: b
a. Functions of resident oral microflora that contribute to colonisation resistance include
competition for receptors for adhesion, not provision of receptors.
b. Correct. Colonisation resistance involves the resident microflora from preventing colo-
nisation by exogenous microorganisms.
c. The production of inhibitory substances is one of the mechanisms by which the resident
microflora prevents colonisation and growth of exogenous microorganisms.
d. Colonisation resistance does not involve the provision of endogenous nutrients for the
growth of exogenous species.
REF: Functions of the climax community: colonisation resistance, p. 62
51. ANS: d
a. Metabolism of endogenous substrates is the means by which bacteria receive nutrients
from the host.
b. Increase in the intake of fermentable carbohydrates could tip the balance of the resident
microflora, but it is not likely to affect colonisation resistance.
c. The use of an alcohol-based oral rinse has not demonstrated colonisation resistance
impairment.
d. Correct. Long-term use of broad spectrum antibiotics can reduce the resident microflora
and thereby impair colonisation resistance.
REF: Functions of the climax community: colonisation resistance, pp. 61–63
52. ANS: a
a. Correct. The fluctuating conditions of nutrient supply (feast–famine) and environmental
change require the oral microflora to possess biochemical flexibility.
b. The pattern of metabolism is closely related to whether the resident microflora enjoys a
pathogenic or commensal relationship with the host.
c. The pattern of metabolism is closely related to whether the resident microflora enjoys a
pathogenic or commensal relationship with the host.
d. Nutrients are derived mainly from the metabolism of endogenous substrates present in
saliva and gingival crevicular fluid (GCF), and these often require the concerted action
of consortia of microorganisms.
REF: Metabolism of oral bacteria, p. 63
53. ANS: a
a. Correct. Starches and not sucrose are broken down by amylases of salivary and bacterial
origin.
b. Sucrose can be broken down by extracellular bacterial invertases.
c. Sucrose can be transported intact as a disaccharide.
d. Sucrose can be used extracellularly by glycosyltransferases.
REF: Metabolism of oral bacteria, pp. 63–64
54. ANS: a
a. Correct. The most significant system is the phosphoenolpyruvate–phosphotransferase
system (PEP-PTS), which is the high-affinity sugar transport system for mono- and
disaccharides in mutans streptococci.
b. The Msm is one of the transport mechanisms, but not the most significant one.
c. Glucose permease is one of the transport mechanisms, but not the most significant one.
d. GTF are involved in the synthesis of glucans.
55. ANS: c
a. The Msm is capable of transporting various common sugars including sucrose, melibiose,
raffinose and maltose (a derivative of starch).
b. Binding protein will not reduce toxic intracellular levels of glycolic intermediates.
c. Correct. Under conditions of carbohydrate excess, bacteria reduce toxic intracellular
levels of glycolic intermediates by forming glycogen.
d. The PEP-PTS is a high affinity sugar transport system that is repressed under high sugar
concentrations.
56. ANS: b
a. Acetic, succinic, propionic, valeric, caproic and butyric acids are found in human plaque
sampled after overnight fasting.
b. Correct. Acetic, succinic, propionic, valeric, caproic and butyric acids are found in human
plaque sampled after overnight fasting.
c. Acetic, succinic, propionic, valeric, caproic and butyric acids are found in human plaque
sampled after overnight fasting.
d. Lactic acid is the main end product formed following the ingestion of high concentrations
of sucrose.
57. ANS: a
a. Correct. S. mutans uses sucrose to produce water-insoluble and soluble glucans, which
are polymers of glucose.
b. Peptidoglycan is a cell wall component with a complex structure.
c. Levans are a polymer of fructose.
d. Inulin is a polymer of fructose.
58. ANS: c
a. High odour producers have higher bacterial load on the tongue and higher numbers of
Gram negative anaerobes.
b. High odour producers have higher bacterial load on the tongue and higher numbers of
c. Correct. High odour producers have higher bacterial load on the tongue and higher
numbers of Gram negative anaerobes.
d. High odour producers have higher bacterial load on the tongue and higher numbers of
C H A P T E R 5
Dental Plaque
Multiple Choice
1. Which of the following is the general term for the complex microbial community that
develops on the tooth surface?
a. Calculus.
b. Saliva.
c. Dental plaque.
d. Dental stain.
2. Dental plaque is an example of which of the following?

a. Pellicle.
b. Biofilm.
c. Salivary mucin.
d. Planktonic community.
3. Which of the following is a property of biofilms and is of clinical significance?

a. Facilitate stain formation.
b. Increase sensitivity to antibiotics.
c. Extremely tolerant of antimicrobial agents.
d. Enhance the development of halitosis.
4. Which of the following is a general property of biofilms?

a. Susceptible to host defences.
b. Limited habitat range.
c. Open architecture.
d. Reduced virulence.
5. Which of the following is a component that is not present in the acquired enamel pellicle?
a. Glucan.
b. Proline-rich peptides.
c. Glucosyltransferases.
d. Enolase.
6. The formation of pellicle starts how long after a clean tooth surface is exposed to the oral
environment?
a. After the attachment of pioneer bacteria.
b. Within 90–120 minutes.
c. As soon as the tooth surface is cleaned (within seconds).
d. After >2 hours.
59
60 5—Dental Plaque
7. Which of the following is true about how the majority of microorganisms are generally
transported to the tooth surface?
a. Carried by food particles.
b. Salivary flow.
c. Tooth brushing.
d. Bacterial motility.
8. The weak physicochemical interactions that facilitate bacterial adhesion to the acquired
pellicle may become irreversible due to which of the following?
a. Interactive energy.
b. Hydrophobicity.
c. High ionic strength.
d. Adhesin-receptor interactions.
9. Which of the following organisms attach to a clean enamel surface as pioneer species of
bacteria in the development of dental plaque?
a. Coccal.
b. Rod shaped.
c. Filament shaped.
d. Spiral shaped.
10. Which of the following terms describes hidden receptors for bacterial adhesins?
a. Glucan.
b. Fimbriae.
c. Cryptitopes.
d. Fibrinogen.
11. The process by which plaque microflora becomes more diverse over time is described by
a. Microbial succession.
b. Aggregation.
c. Adhesin.
d. Desquamation.
12. Pioneer species interact directly with the acquired pellicle while subsequent biofilm forma-
tion is dependant on which of the following?
a. Intergeneric coadhesion.
b. Electrostatic attractive forces.
c. Ability to actively detach.
d. Gradient formation.
13. Of the following, which term describes the ability of individual bacterial cells to be able to
communicate with, and respond to, neighbouring cells?
a. Gene transfer.
b. Food webs.
c. Cross-talk.
d. Quorum sensing.
5—Dental Plaque 61
14. Which of the following are the weak, long-range forces that promote attachment of a bac-
terium to a surface?
a. Electromagnetic energy.
b. Hydrophobicity.
c. Van der Waals forces.
d. Cryptitopes.
15. Early colonisers, such as Neisseria spp., are able to do which of the following in order to
provide more favourable conditions for the growth of obligately anaerobic bacteria?
a. Synthesise proline-rich proteins.
b. Produce exopolymers.
c. Remove sialic acid from host proteins.
d. Consume oxygen and produce carbon dioxide.
16. The lectin-mediated interaction between streptococci and Actinomyces can be blocked by
a. Galactose.
b. Peptides.
c. Glucans.
d. Proline-rich proteins.
17. Which of the following represents the mean doubling time in the early stages of oral plaque
growth?
a. 20 minutes.
b. 5–6 hours.
c. 1–2 hours.
d. 12–15 hours.
18. Which of the following is not a consequence of biofilm formation?

a. Up-regulation of genes involved with bacterial cell motility.
b. Enhanced cell-cell signalling.
c. Enhanced horizontal gene transfer.
d. Reduced sensitivity to antimicrobial agents.
19. Susceptible organisms can appear antibiotic-resistant if neighbouring cells secrete which of
the following?
a. Glucosyltransferases.
b. Glucans.
c. Proline-rich proteins.
d. Drug-degrading enzymes.
20. Increased tolerance of biofilm cells to antimicrobial agents is not related to which of the
following?
a. Increased age of the biofilm.
b. Being part of a plaque community.
c. Rapid microbial growth rates.
d. Limited penetration of the agent.
21. Which of the following is a major factor in the accumulation of biofilms on teeth?
a. A balance between adhesion, growth and removal.
b. Sugar intake.
c. Desquamation.
d. The use of fluoride.
22. Which of the following is responsible for the varied structure seen microscopically in cross-
sections of plaque biofilms?
a. Impacted food particles.
b. A limited number of bacterial types.
c. A higher degree of morphological diversity.
d. Bacterial succession.
23. Decreased sensitivity of early bacterial colonisers of the tooth surface to antimicrobial agents
is due to which of the following?
a. Dehydration.
b. Presence of the acquired pellicle.
c. Bacteria growing in a biofilm.
d. A limited diversity of organisms.
24. Which of the following results from the preparation of material for electron microscopy?
a. Open architecture.
b. Dehydration of the sample.
c. Channels filled with extracellular polymers.
d. Coaggregation.
25. Which of the following factors directly influences the growth of the resident microflora?
a. Bacterial succession.
b. Impacted food particles.
c. Dentures.
d. Endogenous nutrients.
26. The predominant cultivable microflora of the healthy gingival crevice includes large percent-
ages of which of the following?
a. Mutan steptococci.
b. Neisseria.
c. Gram positive facultatively anaerobic rods.
d. Lactobacilli.
27. The microbial composition of dental plaque from animals is studied for which of the fol-
lowing reasons?
a. To evaluate the composition of plaque fluid.
b. To understand the significance of endogenous nutrients.
c. To determine the similarity between microflora of animals and humans.
d. To understand bacterial succession.
28. Plaque fluid can be separated from microbial components by which of the following methods?
a. Centrifugation.
b. Plaque sampling.
c. Isolation techniques.
d. Coadhesion.
29. The development of a food chain between Streptococcus mutans and Veillonella spp., when the
former is metabolising fermentable sugars, results in which of the following?
a. More lactic acid.
b. More caries.
c. Propionic and acetic acids, and more caries.
d. Propionic and acetic acids, and fewer caries.
30. Which of the following is the term used to describe calcified dental plaque?
a. Apatite.
b. Pyrophosphates.
c. Calculus.
d. Mineral growth.
31. Which of the following describes calculus that is found below the gingival margin?
a. Whitlockite.
b. Subgingival.
c. Apatite.
d. Supragingival.
32. Which of the following ingredient in oral care products reduces calculus formation?
a. Pyrophosphate.
b. Sodium lauryl sulphate.
c. Fluoride.
d. Calcium.
33. What is the percentage of adults who have calculus?

a. 50%.
b. >80%.
c. 10%.
d. 35%.
34. Which of the following is not an example of a synergistic microbial interaction?

a. Enzyme complementation.
b. Coadhesion.
c. Bacteriocin production.
d. Food web formation.
35. Individual species of oral bacteria possess different but overlapping patterns of which of the
following to gain nutrients from host mucins?
a. Bacteriocins.
b. Glycosidases.
c. Glucosyltransferases.
d. Phosphotransferases.
36. Which of the following is one of the primary ecological determinants in dictating the preva-
lence of a particular species in supragingival dental plaque?
a. Competition for endogenous nutrients.
b. Salivary flow.
c. Presence of gingival crevicular fluid (GCF).
d. Diet.
37. Which of the following is not an example of an antagonistic interaction?

a. Hydrogen peroxide production.
b. Organic acid and low pH formation.
c. Nutrient competition.
d. Cell-cell signalling.
38. When lactate, produced from the metabolism of dietary carbohydrates from a range of bacte-
rial species, is used as a nutrient by another species, the lactate-consuming species is known
as which of the following?
a. Primary feeder.
b. Antagonistic species.
c. Secondary feeder.
d. Mutually dependant.
39. Which of the following is not a major contributing factor in the organised manner in which
dental plaque forms?
a. Interbacterial coadhesion.
b. Interbacterial metabolic interactions.
c. Gene transfer.
d. Cell-cell communication.
40. Which of the following is a benefit of the microbial community lifestyle to the component
species?
a. Reduction of protection from host defences.
b. Limited habitat range.
c. Increased sensitivity to antimicrobial agents.
d. Increased metabolic efficiency.
41. Which of the following is not a ‘non-immunological’ factor responsible for the breakdown
of microbial homoeostasis in dental plaque?
a. Xerostomia.
b. Broad spectrum antibiotic treatment.
c. Infection-induced myelosuppression.
d. Increased gingival crevicular fluid flow.
42. Which of the following is not a property of the matrix of microbial biofilms?
a. Restricts the penetration of charged antimicrobial agents.
b. Contributes to the structural integrity of the biofilm.
c. Retains nutrients and enzymes within the biofilm.
d. Increases desiccation.
43. Which of the following is not an immunological factor responsible for the breakdown of
microbial homoeostasis in dental plaque?
a. Xerostomia.
b. Neutrophil dysfunction.
c. sIgA deficiency.
d. Chemotherapy-induced myelosuppression.
Feedback
1. ANS: c
a. Plaque that becomes calcified is referred to as calculus or tartar.
b. Saliva is the fluid in the mouth that carries multiple components that play a significant
role in the homoeostasis of the oral cavity.
c. Correct. Dental plaque is a general term for the complex microbial community that
develops on the tooth surface.
d. Dental stain is the chromogenic formation of colour within the pellicle derived from
various dietary components.
REF: Chapter introduction, p. 74
2. ANS: b
a. Pellicle is a surface film that salivary proteins and glycoproteins form as soon as a tooth
surface is cleaned.
b. Correct. The term biofilm is used to describe communities of microorganisms attached
to a surface.
c. Salivary mucins are high-molecular-weight glycoproteins.
d. A planktonic community would be one in liquid culture, not growing as a biofilm like
dental plaque.
REF: Microbial biofilms, pp. 75–76
3. ANS: c
a. Biofilms provide a surface to which chromogenic elements from various dietary compo-
nents can adsorb.
b. Oral bacteria growing as a biofilm such as dental plaque display a markedly reduced
sensitivity to antibiotics.
c. Correct. Biofilms can be up to 1000 times more tolerant of antimicrobial agents than
the same cells growing in liquid culture.
d. Biofilm provides an adherent surface to which microbial populations that produce com-
pounds associated with halitosis can adhere.
REF: Microbial biofilms, p. 75
4. ANS: c
a. Protection from host defences including the production of extracellular polymers to form
a functional matrix providing physical protection from phagocytosis is a general property
of biofilms.
b. A broader habitat range is a general property of biofilms.
c. Correct. Biofilms have been shown to have an ‘open architecture’ with the presence of
channels and voids.
d. A general property of biofilms is an enhanced virulence and a pathogenic synergism in
abscesses and periodontal diseases.
REF: Microbial biofilms, p. 76
5. ANS: d
a. Bacterial components such as glucosyltransferases and glucan can be detected in
pellicle.
b. Proline-rich peptides can be found in the acquired enamel pellicle.
c. Bacterial components such as glucosyltransferases and glucan can be detected in
pellicle.
d. Correct. Enolase is an intracellular enzyme found in oral bacteria, but is not a major
component of the acquired pellicle.
REF: Acquired pellicle formation, p. 78
6. ANS: c
a. Salivary proteins and glycoproteins are adsorbed to a clean tooth surface forming acquired
enamel pellicle before the attachment of pioneer bacterial species.
b. An equilibrium between adsorption and desorption of salivary molecules occurs after
90–120 minutes.
c. Correct. As soon as (within seconds) a tooth surface is cleaned, salivary proteins and
glycoproteins are adsorbed forming a surface conditioning film which is termed the
acquired enamel pellicle.
d. After 2 hours, the pellicle on lingual surfaces is 20–80 nm thick whereas buccal pellicles
can be 200–700 nm deep.
REF: Acquired pellicle formation, p. 78
7. ANS: b
a. Dietary components have little influence on the composition of oral microflora, although
the frequent intake of fermentable carbohydrates can lead to increases in acidogenic and
aciduric organisms.
b. Correct. Microorganisms are generally transported passively to the tooth surface by the
flow of saliva.
c. Colonisation of bacteria on the tooth surface is not associated with tooth brushing.
d. Few oral bacterial species are motile (e.g., possess flagella), and these are mainly located
subgingivally.
REF: Transport of microorganisms and reversible attachment, p. 79
8. ANS: d
a. The physicochemical interactions may become irreversible due to adhesins on the micro-
bial cell surface becoming involved with receptors in the acquired pellicle.
b. The physicochemical interactions may become irreversible due to adhesins on the micro-
c. The physicochemical interactions may become irreversible due to adhesins on the micro-
d. Correct. Within a short time, the physicochemical interactions may become irreversible
due to adhesins on the microbial cell surface becoming involved with receptors in the
acquired pellicle.
REF: Pioneer microbial colonisers and irreversible attachment (adhesin–receptor interac-

tions), p. 80
9. ANS: a
a. Correct. Coccal bacteria attach to the enamel pellicle as pioneer species on a clean enamel
surface in the development of dental plaque; many of these bacteria are streptococci.
b. With time, the diversity of the microflora increases, and rod and filament-shaped bacteria
colonise.
c. With time, the diversity of the microflora increases, and rod and filament-shaped bacteria
colonise.
d. Spiral-shaped bacteria (i.e., spirochaetes) are late colonisers of the tooth surface, and are
usually found subgingivally.

tions), p. 80
10. ANS: c
a. Glucans are the receptor for adhesins for mutans streptococci.
b. Fimbriae are surface structures on bacteria.
c. Correct. Hidden receptors for bacterial adhesins have been termed cryptitopes.
d. Fibrinogen is the receptor for adhesins for Porphyromonas gingivalis.

tions), p. 82
11. ANS: a
a. Correct. Microbial succession is the term used to describe the change in plaque micro-
flora that occurs over time due to a series of complex interactions.
b. Aggregation involves cell-to-cell binding in saliva, leading to the removal of the bacteria
by swallowing.
c. Adhesins facilitate the irreversible attachment of cells to the tooth that involves specific
interactions between components on the microbial cell surface.
d. Desquamation is the shedding of epithelial cells, which helps reduce the microbial load
on mucosal surfaces.
REF: Coaggregation/coadhesion and microbial succession, pp. 82–83
12. ANS: a
a. Correct. Pioneer species interact directly with the acquired pellicle while subsequent
biofilm formation is dependant on intra- and intergeneric coadhesion between bacteria.
b. Electrostatic attractive forces are part of the early and reversible attachment of pioneer
organisms to the conditioned tooth surface.
c. If conditions become unfavourable, some cells are able to actively detach, providing the
opportunity to colonise other sites.
d. It has been shown that considerable gradients in key factors (pH, redox potential, etc.)
can occur over relatively short distances within biofilms.
REF: Detachment from surfaces, p. 85
13. ANS: d
a. Gene transfer involves the one-way transfer of genetic material between bacteria.
b. Food webs are examples of nutritional interdependancies between bacteria.
c. Certain members of the resident microflora can also engage in ‘cross-talk’ with the host,
for example, by down-regulating the potential induction of proinflammatory cytokines.
d. Correct. Quorum sensing is the term used to describe the ability of individual cells to
communicate with, and respond to, neighbouring cells by means of small, diffusible,
effector molecules.
REF: Cell-cell signalling, p. 86
14. ANS: c
a. Van der Waals forces can promote reversible attachment.
b. Van der Waals forces can promote reversible attachment.
c. Correct. Van der Waals forces can promote reversible attachment.
d. Crytitopes are involved in strong irreversible attachment.
REF: Transport of microorganisms and reversible attachment, p. 79
15. ANS: d
a. Proline-rich proteins are not synthesised by Neisseria spp.
b. Exopolymers do not promote the growth of obligately anaerobic bacteria.
c. The removal of sialic acid from host proteins would not promote the growth of obligately
anaerobic bacteria.
d. Correct. Early colonisers such as Neisseria spp. can consume oxygen and produce carbon
dioxide gradually allowing conditions to become more favourable for the growth of
obligately anaerobic bacteria.
REF: Coaggregation/coadhesion and microbial succession, p. 83
16. ANS: a
a. Correct. Coaggregation often involves lectins, and the lectin-mediated interaction
between streptococci and Actinomyces can be blocked by adding galactose or lactose.
b. The metabolism of pioneer species generates nutrients such as peptides that can be used
by other organisms as primary nutrient sources.
c. Glucans are extracellular polymers synthesised by some adherent bacteria which make a
major contribution to the plaque matrix.
d. Proline-rich proteins are receptors for Actinomyces naeslundii.
REF: Coaggregation/coadhesion and microbial succession, p. 83
17. ANS: c
a. Doubling times of oral bacteria in vivo are slower than every 20 minutes.
b. Early bacterial colonisers divide more rapidly than every 5–6 hours.
c. Correct. The growth rate of individual bacteria during the early stages of plaque forma-
tion has a mean doubling time of 1–2 hours.
d. The growth rate of individual bacteria within plaque slows as the biofilm matures, and the
mean doubling time becomes between 12–15 hours after 1–3 days of biofilm development.
REF: Mature biofilm formation, p. 83
18. ANS: a
a. Correct. Genes associated with cell motility are down-regulated in biofilms, as the cells
now become sessile.
b. Cells have enhanced opportunity for cell-cell signalling in biofilms.
c. Horizontal gene transfer is enhanced in a biofilm.
d. Microorganisms have a reduced sensitivity to antimicrobial agents in a biofilm.
REF: Consequences of biofilm formation, pp. 85–87
19. ANS: d
a. Bacterial components such as glucosyltransferases, detected in pellicle, play a significant
role in attachment.
b. Glucans are an extracellular polymers synthesised by some adherent bacteria which make
a major contribution to the plaque matrix.
c. Proline-rich proteins are receptors for A. naeslundii.
d. Correct. Being part of a microbial community can influence the sensitivity of cells to an
antibiotic; susceptible organisms can appear resistant if neighbouring cells secrete a drug-
degrading enzyme, such as beta-lactamase.
REF: Antimicrobial tolerance, p. 87
20. ANS: c
a. Older biofilms appear less susceptible to antimicrobial agents than younger biofilms.
b. Being part of a microbial community can increase the tolerance of a microbe to an anti-
microbial agent due to the production of a neutralising enzyme by neighbouring cells.
c. Correct. The mechanisms that cause the increased tolerance of biofilm cells to anti
microbial agents include slow microbial growth rates.
d. Increased tolerance of biofilm cells to antimicrobial agents are attributed to limited
penetration, inactivation by neutralising enzymes, quenching, unfavourable environmen-
tal conditions for activity, slow microbial growth rates, and expression of a novel microbial
phenotype.
21. ANS: a
a. Correct. The accumulation of plaque on teeth is the result of the balance between adhe-
sion, growth and removal of microorganisms.
b. The ingestion of refined carbohydrate does impact on plaque growth, but is not a major
factor. Accumulation is most influenced by a balance between adhesion, growth and
removal.
c. Desquamation is a major factor in the control of biofilm formation on mucosal surfaces
(not teeth).
d. The use of fluoride contributes in a minor capacity to one of the three factors affecting
accumulation: adhesion, growth and removal.
REF: Structure of mature dental plaque, p. 87
22. ANS: d
a. Impacted food particles are not involved in the various stages of plaque formation.
b. A limited number of bacterial types are involved in one stage of plaque development.
c. Plaque development includes the development of a higher degree of morphological
diversity at one stage.
d. Correct. Bacterial succession is responsible for the ‘layering’ effect that takes place in
plaque maturation with an initial limited number of bacterial types followed by the
formation of a bulk layer showing higher morphological diversity.
23. ANS: c
a. Dehydration is not a feature that relates to the decreased sensitivity to antimicrobial agents.
b. The presence of the acquired pellicle does not affect the sensitivity of bacteria to anti-
microbial agents.
c. Correct. Cells in biofilms display a decreased sensitivity to antimicrobial agents.
d. The limited diversity of organisms displayed in early plaque development is not indicative
of a decreased sensitivity to antimicrobial agents.
24. ANS: b
a. Open architecture of a sample is the result of it being viewed by confocal microscopy but
is not a result of the preparation of the slide for electron microscopy.
b. Correct. The preparation of material for electron microscopy dehydrates the sample and
distorts the natural structure of biofilms.
c. Channels filled with extracellular polymers are not related to the preparation of material
for electron microscopy.
d. Co-aggregation is an interaction among bacteria to aid in colonisation and is not involved
in material preparation for electron microscopy.
25. ANS: d
a. Bacterial succession does not directly influence the growth of resident microflora.
b. Impacted food particles do not directly influence the growth of resident microflora.
c. Dentures do not influence the growth of resident microflora.
d. Correct. Factors that influence the growth of the resident microflora include the provi-
sion by the host of endogenous nutrients.
REF: Bacterial composition of the climax community of dental plaque from different sites, p. 90
26. ANS: c
a. Mutan streptococci are not predominant cultivable microflora of the healthy gingival
crevice.
b. Neisseria is not predominant cultivable microflora of the healthy gingival crevice.
c. Correct. Gram positive facultatively anaerobic rods are among the predominant cultiva-
ble microflora of the healthy gingival crevice.
d. Lactobacilli are not the predominant cultivable microflora of a healthy gingival crevice.
REF: Gingival crevice plaque, p. 94
27. ANS: c
a. Evaluating the composition of plaque fluid in animals is not a reason that there is interest
in the microbial composition of dental plaque from animals.
b. Understanding endogenous nutrients is not a reason that there is interest in the microbial
composition of dental plaque from animals.
c. Correct. There is interest in the microbial composition of dental plaque from animals
for two main reasons: (a) to study the influence of widely different diets and lifestyles on
the microflora and (b) to determine the similarity between the microflora of an animal
and that of humans to ascertain their relevance as a model of human oral disease.
d. Understanding bacterial succession is not a reason that there is interest in determining
the similarity between microflora of animals to humans.
REF: Dental plaque from animals, p. 94
28. ANS: a
a. Correct. Plaque fluid is the free aqueous phase of plaque and can be separated from the
microbial components by centrifugation.
b. Plaque sampling is a method of collection, not the manner in which plaque fluid can be
separated from the microbial components.
c. Isolation techniques are not used in the separation of plaque fluid from microbial
components.
d. Coadhesion is a factor involved in beneficial microbial interaction in dental plaque.
REF: Plaque fluid, p. 95
29. ANS: d
a. The Veillonella spp. consume lactic acid, not generate more lactate.
b. The Veillonella spp., by consuming lactic acid and producing weaker acids, reduce caries
in an animal model.
c. Propionic and acetic acids are the products of the food chain, but these are weaker acids,
and so there are fewer caries in an animal model.
d. Correct. Propionic and acetic acids are the products of the food chain, and result in fewer
caries in an animal model because they are weaker acids than lactate.
REF: Microbial interactions in dental plaque, Figure 5.14, pp. 96–97
30. ANS: c
a. Apatite is a component of calculus.
b. Pyrophosphate inhibits the formation of calculus and is used in dental products.
c. Correct. Calculus, or tartar, is the term used to describe calcified dental plaque.
d. Mineral growth is the process of bacteria being coalesced to form calculus.
REF: Calculus, p. 96
31. ANS: b
a. Whitlockite is a component of calculus.
b. Correct. Calculus found below the gingival margin is called subgingival calculus.
c. Apatite is a component of calculus.
d. Supragingival calculus is found above the gingival margin.
32. ANS: a
a. Correct. Pyrophosphate is commonly found in dental products formulated to restrict the
formation of calculus.
b. Sodium lauryl sulphate does not inhibit calculus formation in dental products.
c. Fluoride does not inhibit calculus formation.
d. Calcium is not found in dental products to restrict the formation of calculus.
33. ANS: b
a. No – more than 80% of adults have calculus.
b. Correct. More than 80% of adults have calculus.
c. No – more than 80% of adults have calculus.
d. No – more than 80% of adults have calculus.
34. ANS: c
a. Bacteria pool their enzyme resources in order to catabolise complex host molecules such
as mucins.
b. Coadhesion enables later colonisers to bind to already attached early bacterial colonising
bacteria.
c. Correct. Bacteriocins are inhibitory products produced by some oral bacteria.
d. Food webs enable secondary feeders to utilise the products of metabolism of primary
feeders in a microbial community such as dental plaque.
REF: Synergistic interactions, Table 5.9, p. 96
35. ANS: b
a. Bacteriocins are inhibitory factors that are involved in microbial interactions but do not
have a role in patterns of enzyme activity.
b. Correct. Individual species of oral bacteria possess different but overlapping patterns of
glycosidase activity.
c. Glucosyltransferases are involved in the synthesis of glucans.
d. Phosphotransferases are involved with sugar transport in bacteria.
REF: Synergistic interactions, pp. 96–97
36. ANS: a
a. Correct. Competition for host-derived nutrients is one of the primary ecological deter-
minants in dictating the prevalence of a particular species in dental plaque.
b. Salivary flow and swallowing play a role in plaque removal.
c. The presence of GCF does not dictate the prevalence of a particular species in supra
gingival dental plaque; its main influence is on subgingival biofilms.
d. Diet has a limited influence on determining the composition of dental plaque.
REF: Synergistic interactions, pp. 96–97
37. ANS: d
a. Hydrogen peroxide is inhibitory to the growth of many oral bacteria.
b. Acid production, and the generation of a low pH, is inhibitory to many oral bacteria.
c. Competition for nutrients is a major factor determining which oral bacteria will be able
to colonise and grow successfully.
d. Correct. Cell-cell signalling (or quorum sensing) is a mechanism by which bacteria
within a microbial community are able to coordinate their gene expression, etc.
REF: Antagonistic interactions, Table 5.9, pp. 96–99
38. ANS: c
a. A primary feeder is a bacterial species that produces, through its own metabolic process,
nutrients for another species.
b. An antagonistic species is one producing an inhibitory factor.
c. Correct. A secondary feeder is a bacterial species that uses the metabolic by-products of
one species as its own nutritional source.
d. Mutual dependance is a relationship between bacteria in which both bacteria (lactate
producer and lactate consumer) are dependant on one another.
REF: Synergistic interactions, p. 97
39. ANS: c
a. Plaque forms in an organised manner by interbacterial coadhesion, metabolic interactions
and cell–cell communication.
b. Plaque forms in an organised manner by interbacterial coadhesion, metabolic interactions
c. Correct. Gene transfer is not one of the major contributing factors in the formation of
dental plaque.
d. Plaque forms in an organised manner by interbacterial coadhesion, metabolic interactions
REF: Dental plaque as a microbial community, p. 99
40. ANS: d
a. A reduction in the protection from host defences is not a benefit of the microbial com-
munity lifestyle; rather, microbial communities display an increased protection.
b. A limited habitat range is not a benefit of the microbial community lifestyle to the
component species; rather, microbial communities display an extended habitat range.
c. An increase in sensitivity to antimicrobial agents is not a benefit of the microbial com-
munity lifestyle to the component species; rather, microbial communities display a
decreased sensitivity by, for example, cross-protection of a sensitive species by a resistant
species.
d. Correct. An increased metabolic efficiency via food webs and the pooling of enzyme
capabilities is a benefit of the microbial community lifestyle to the component species.
REF: Dental plaque as a microbial community summary, p. 99
41. ANS: c
a. Xerostomia is a non-immunological factor that can cause a breakdown in microbial
homoeostasis.
b. Broad spectrum antibiotics can disrupt microbial homoeostasis.
c. Correct. Infections such as acquired immunodeficiency syndrome (AIDS) affect the
integrity of the host defences which causes a breakdown in microbial homoeostasis.
d. Increased GCF flow is a non-immunological factor than can disrupt microbial homoe-
ostasis in the gingival crevice.
REF: Microbial homoeostasis in dental plaque, p. 101, and Table 5.10
42. ANS: d
a. The matrix can restrict the penetration of charged antimicrobial agents into the biofilm.
b. The matrix does act as a chemical scaffold to maintain the structural integrity of
biofilms.
c. The matrix does retain nutrients and enzymes within the biofilm.
d. Correct. The matrix also retains water within the biofilm and so prevents desiccation.
REF: Mature biofilm formation, pp. 83–85
43. ANS: a
a. Correct. Xerostomia is the reduced flow of saliva and is, therefore, not an immunological
factor responsible for the breakdown of microbial homoeostasis in dental plaque.
b. Neutrophil dysfunction is an immunological factor responsible for the breakdown of
microbial homoeostasis in dental plaque.
c. sIgA-deficiency is an immunological factor responsible for the breakdown of microbial
homoeostasis in dental plaque.
d. Chemotherapy-induced myelosuppression is an immunological factor responsible for the
breakdown of microbial homoeostasis in dental plaque.
REF: Microbial homoeostasis in dental plaque; Table 5.10, p. 101
C H A P T E R 6

Plaque-Mediated
Diseases—Dental Caries
and Periodontal Diseases
Multiple Choice
1. Historically, for any microbe to be considered responsible for a given condition, Koch’s
postulates were applied. Which of the following is not one of the original Koch’s
postulates?
a. Elimination of the microbe should result in clinical improvement.
b. A microbe should be present in sufficient numbers to initiate disease.
c. Disease is considered to be the outcome of the overall activity of the total plaque
microflora.
d. The microbe should produce relevant virulence factors.
2. Which of the following is not one of the hypotheses relating the composition of dental plaque
to caries or periodontal diseases?
a. Specific plaque hypothesis.
b. Non-specific plaque hypothesis.
c. Homeostatic hypothesis.
d. Ecological plaque hypothesis.
3. Which of the following is a tenet of the specific plaque hypothesis?

a. Disease is the outcome of the overall activity of the total plaque microflora.
b. Only a few species out of the diverse collection of organisms comprising the resident
plaque microflora are actively involved in disease.
c. Plaque-mediated diseases are essentially mixed culture (polymicrobial) infections.
d. A high antibody titre to the microbe should be detected during infection; this may provide
protection on subsequent reinfection.
4. Which best represents the general concept of the ecological plaque hypothesis?
a. The microbe should generate high levels of specific antibodies.
b. The microbes should produce relevant virulence factors.
c. The organisms associated with disease may also be present at sound sites, but at levels
too low to be clinically relevant, but are selected and may increase markedly in number
following a change in local environmental conditions.
d. Plaque-mediated diseases are essentially mixed culture (polymicrobial) infections, but in
which only certain species are able to predominate.
75
76 6—Plaque-Mediated Diseases—Dental Caries and Periodontal Diseases
5. Which type of epidemiological survey will determine most accurately the role of plaque
bacteria in dental disease and establish a cause-and-effect relationship?
a. Longitudinal.
b. Observational.
c. Cross-sectional.
d. Prospective.
6. Which of the following best defines the dental caries process?

a. Aggressive enamel destruction.
b. Destruction of the cementum.
c. Localised destruction of the tissues of the tooth by bacterial fermentation of dietary
carbohydrates.
d. Demineralisation of the root surface.
7. Caries of enamel surfaces are particularly common up to the age of 20 years; whereas, in
later life, which of the following becomes an increasing problem?
a. Pit and fissure caries.
b. Interproximal caries.
c. Buccal-surface caries.
d. Root-surface caries.
8. Which of the following best describes the initial carious lesion?

a. Small demineralised areas below the surface of the enamel.
b. Demineralisation of the cementum.
c. Small demineralised areas that penetrate through the enamel.
d. The initial carious lesion is seen interproximally.
9. Which of the following results in the acid formation that initiates enamel demineralisation?
a. Consumption of highly acidic foods.
b. Microbial fermentation of dietary carbohydrates.
c. Limited use of dental floss.
d. Dry mouth associated with various medicinal products.
10. Which of the following can occur in the initial stages of dental caries production, particularly
in the presence of fluoride?
a. Rapid cavitation.
b. Gingival recession.
c. Remineralization.
d. Further demineralisation.
11. Which of the following streptococci have been implicated in dental caries?
a. Streptococcus sanguinis.
b. Streptococcus sobrinus.
c. Streptococcus salivarius.
d. Streptococcus oralis.
12. Which of the following represents the tooth surface most prone to caries?
a. Approximal.
b. Buccal surface.
c. Fissures on occlusal surfaces.
d. Lingual surface.
6—Plaque-Mediated Diseases—Dental Caries and Periodontal Diseases 77
13. Which of the following is the term applied to caries that recur beneath and around previous
restorations?
a. Rampant caries.
b. Periodic caries.
c. Bottle caries.
d. Secondary caries.
14. Which of the following is the main source for mutans streptococci found in pre-dentate infants?
a. Father.
b. Mother.
c. Exposure to sugar.
d. Grandparents.
15. The prevalence of root surface caries increases with age; what approximate percentage of
individuals aged 60 years or older have root caries or fillings?
a. 10%.
b. 25%.
c. 60%.
d. >90%.
16. Which of the following groups of microorganisms are most commonly linked to enamel
dental caries?
a. Mutans streptococci and Candida.
b. Mutans streptococci and lactobacilli.
c. Lactobacilli and Actinomyces.
d. Mutans streptococci and Actinomyces.
17. The microflora associated with root surface caries is diverse; which of the following groups
of bacteria are most commonly reported to be present in root surface lesions?
a. Actinomyces and Veillonella.
b. Lactobacilli and Veillonella.
c. Mutans streptococci, lactobacilli and Actinomyces.
d. Lactobacilli, Veillonella and Prevotella.
18. Which of the following characteristics do not contribute to the cariogenicicty of mutans
streptococci?
a. Rapid sugar transport.
b. Low tolerance of external acidic pH.
c. Extracellular polysaccharide (EPS) production from sucrose.
d. Intracellular polysaccharide (IPS) production.
19. Which of the following can occur when the gingival crevice becomes inflamed?
a. Microflora becomes predominately aerobic.
b. The pH drops.
c. The crevice deepens to become a pocket.
d. The temperature in the crevice/pocket drops.
20. When attempting to determine the microflora of a periodontal pocket, care has to be taken
to preserve the viability of which of the following organisms?
a. Obligately anaerobic species.
b. Aerobic species.
c. Gram negative species.
d. Asaccharolytic bacteria.
21. Which of the following changes in local subgingival environment is involved in the disease
process?
a. The environment favours the growth of aerobic bacteria.
b. A decrease in temperature.
c. An increase in pH.
d. A decrease in flow of gingival crevicular fluid (GCF).
22. Which of the following is not one of the main types of periodontal diseases?
a. Chronic periodontitis.
b. Gingival diseases.
c. Acute periodontitis.
d. Necrotising forms of periodontal disease.
23. Which of the following would not be considered a modifier of chronic and aggressive
periodontitis?
a. Leukaemia.
b. Diabetes.
c. Pneumonia.
d. Smoking.
24. Which of the following is not a characteristic of chronic marginal gingivitis?

a. Non-specific host response.
b. Reversible.
c. Non-reversible.
d. Inflammatory response.
25. What percentage of the dentate population is affected by gingivitis at some stage?
a. 40%.
b. 50%.
c. 75%.
d. 100%.
26. Generally, gingivitis is regarded as resulting from a non-specific proliferation of the normal
gingival crevice microflora due to which of the following?
a. Mal-occlusion.
b. Concomitant medication.
c. Co-existing systemic disease.
d. Poor oral hygiene.
27. Which of the following produce exaggerated clinical responses (gingivae more oedematous
and inflamed) to dental plaque?
a. Mal-occlusion.
b. Sleep-apnoea.
c. Hormonal disturbances.
d. Rheumatoid arthritis.
28. Which of the following is not associated with the development of gingivitis?
a. 10–20 fold increase in plaque mass.
b. Shift towards plaque dominated by anaerobic Gram negative bacteria.
c. An increase in the carbohydrate balance in the diet.
29. Which of the following events precede periodontitis?

a. Increased crevicular temperature.
b. Gingivitis.
c. Cariogenic shift in bacteria.
d. Hormonal disturbances.
30. Which of the following is the most common form of advanced periodontal disease affecting
the general population?
b. Gingivitis.
c. Necrotising periodontitis.
d. Aggressive periodontitis.
31. Approximately how many people in the USA suffer from chronic periodontitis during their
life?
a. 10%.
b. 30%.
c. 60%.
d. 75%.
32. Which of the following is not involved in chronic periodontitis?

a. Loss of attachment from gingiva to root surface.
b. Potential inflammation of the periodontal ligament.
c. Increase in aerobic bacteria in the gingival pocket.
d. Bone loss.
33. Which of the following can predispose an individual to chronic periodontitis?

a. Gingival hyperplasia.
b. Overhanging restorations.
c. Mal-occlusion.
d. Toothbrush abrasion.
34. A shift in which of the following bacteria initiate inflammation?

a. Gram positive facultatively anaerobic bacteria.
b. Gram negative facultatively anaerobic bacteria.
c. Gram negative obligate anaerobes.
d. Spirochaetes.
35. Which of the following is not a Gram negative bacterium?

a. Fusobacterium nucleatum.
b. Parvimonas micra.
c. Prevotella intermedia.
d. Porphyromonas gingivalis.
36. Which of the following is found in deep periodontal pockets?

c. Streptococcus intermedius.
d. Capnocytophaga gingivalis.
37. Implicit in the ecological plaque hypothesis is that dental caries can be controlled or pre-
vented by all of the following strategies, except one. Which one of the following is not a
strategy that is consistent with the ecological plaque hypothesis?
a. Directly targeting the putative pathogens.
b. Stimulating saliva flow.
c. Vaccination against Streptococcus mutans.
d. Promoting the use of snacks containing sugar substitutes.
38. One of the theories proposed to explain the emergence of previously undetected species in
a periodontal pocket is which of the following?
a. An increase in Gram positive aerobic organisms.
b. An increase in GCF flow.
c. A mutation in endogenous species.
d. Colonisation by exogenous pathogens from another person.
39. Which of the following periodontal diseases appears as a manifestation of underlying sys-
temic problems such as HIV infection?
a. Necrotizing ulcerative gingivitis (NUG).
b. Chronic periodontitis.
c. Juvenile periodontitis.
d. Cancrum oris.
40. The characteristic unique to NUG is which of the following?

a. Petechiae.
b. Bleeding on probing.
c. A grey pseudomembrane.
d. Excessive salivation.
41. The bacterial pathogen most commonly associated with localised aggressive periodontitis is
a. Porphyromonas gingivalis.
b. Tannerella forsythia.
c. ‘Red complex’ bacteria.
d. Aggregatibacter actinomycetemcomitans.
42. The organisms associated with lesions in NUG include which of the following?
a. Fuso-spirochaetal complex.
b. Prevotella nigrescens and Porphyromonas gingivalis.
c. Mixed community of spirochaetes only.
d. Mixed community of motile bacteria.
43. Rapid clinical improvement can be seen in the treatment of NUG with which of the fol-
lowing drugs?
a. Chlorhexidine.
b. Metronidazole.
c. Penicillin.
d. Tetracycline.
44. Which of the following host factors in GCF could act as predictors of attachment loss?
a. Prostaglandin levels.
b. Gingipain levels.
c. Leukotoxin activity.
d. Antibodies to the ‘red complex’.
45. A 13-year-old female from West Africa presents with localised, rapid onset periodontal
disease producing rapid loss of attachment. The most likely disease category is which of the
following?
b. Necrotising periodontal diseases.
c. Aggressive periodontitis.
d. Acute streptococcal periodontal diseases.
46. The therapy of choice for the elimination of A. actinomycetemcomitans when treating aggres-
sive periodontitis is which of the following?
a. Chlorhexidine plus root planing and scaling.
b. Metronidazole plus root planing and scaling.
c. Amoxicillin and metronidazole plus root planing and scaling.
d. Tetracycline plus root planing and scaling.
47. The damaged neutrophils in the majority of patients with aggressive periodontitis produce
a variety of abnormalities including which of the following?
a. Increased chemotaxis.
b. Increased phagocytosis.
c. Decreased superoxide radical production.
d. Abnormal signal transduction pathways.
48. Which is a major virulence factor produced by A. actinomycetemcomitans?

a. Leukotoxin production.
b. Gingipain production.
c. Lipoteichoic acid.
d. Hydrogen peroxide production.
49. The exaggerated gingivitis seen during the second trimester in pregnancy is linked to an
increase in the proportions of which of the following organisms?
a. A. actinomycetemcomitans.
b. Treponema species.
c. Prevotella intermedia.
d. Actinomyces odontolyticus.
50. A child reports with ulcerated swellings of the gingivae which are acutely painful; lesions appear
on the lips and have lasted approximately 10 days. The cytological smear confirms the presence
of Herpes simplex type 1 (HSV-1). What would be the drug of choice for treatment?
a. Metronidazole.
b. Acyclovir.
c. Penicillin.
d. Tetracycline.
51. The mode of action of fluoride includes inhibition of which of the following?
a. Gingipain, lipopolysaccharide (LPS), leukotoxin.
b. Glycolysis, IPS synthesis, sugar transport.
c. Glycolysis, LPS, sugar transport.
d. Cell wall synthesis, IPS synthesis, sugar transport.
52. In which of the following ways does periodontal disease influence diabetes?
a. Increases pancreatic inflammation.
b. Predisposes the person to diabetes type 2.
c. Decreases blood glucose triggering diabetic incidences.
d. Decreases insulin resistance.
53. Glycaemic control in the diabetic can be improved with which of the following?
a. Antibiotic therapy.
b. Chlorhexidine and root planing.
c. Hydrogen peroxide and root planing.
d. Antiviral therapy.
54. Which of the following is not an artificial sweetener?

a. Aspartame.
b. Casein.
c. Xylitol.
d. Saccharin.
55. The classic form of cancrum oris affects mostly which age group?
a. Pregnant women.
b. Young children.
c. Children at puberty.
d. Elderly.
56. Noma is most common in which of the geographic locations?

a. Scandinavia.
b. North America.
c. Africa.
d. Australasia.
57. The World Health Organization (WHO) estimated that how many children less than 6
years of age contract noma each year?
a. <1000.
b. 30 000.
c. 7>1 000 000.
d. 200 000.
58. Which of the following enables periodontal pathogens to attach to and colonise on the
subgingival tooth surfaces?
a. Capsule.
b. Fimbriae.
c. Protease.
d. Leukotoxin.
59. Which of the following is a virulence factor of P. gingivalis?

a. Lipoteichoic acid (LTA).
b. Ammonia.
c. Gingipain.
d. Leukotoxin.
60. The main defence strategy by the host against periodontal pathogens is via what cell type?
a. Antibodies.
b. Leukocytes.
c. Monocytes.
d. Neutrophils.
61. Hyaluronidase, chondroitin sulphatase and glycylprolyl peptidase are examples of enzymes
involved in which phase of periodontal destruction?
a. Tissue damage.
b. Tissue invasion.
c. Evasion and/or inactivation of host defences.
d. Multiplication of putagenic pathogens.
62. For the establishment of disease, organisms must gain access to and adhere at a susceptible
site, multiply, overcome or evade the host defences, and which of the following?
a. Prevent exogenous invasion.
b. Produce or induce tissue damage.
c. Provide nutrients to the biofilm at the advancing front of the lesion.
d. Induce suppresser T cells.
63. Which of the following is not being considered as a potential predictor of future periodontal
disease activity?
a. Salivary tests for mutans streptococci and lactobacilli.
b. Rapid molecular tests for putative pathogens.
c. Enzyme detection in subgingival plaque.
d. Detection of inflammatory mediators in the GCF.
64. Evidence suggests a potential association between periodontal diseases and general health.
Which of the following is not considered to be linked to periodontal disease?
a. Cardiovascular disease.
b. Aspiration pneumonia.
c. Pre-term labour.
d. Hepatic disorder.
65. The most effective treatment for chronic periodontitis is which of the following?
a. Sealants.
b. Antimicrobial oral rinse.
c. Debridement of the root surfaces.
d. Flossing.
66. The optimum concentration of fluoride supplementation in drinking water for maximal
protection against caries is approximately which of the following?
a. 1 part per million (1 ppm).
b. 10 ppm.
c. 100 ppm.
d. 1000 ppm.
67. Fluoride is also found naturally existing in which of the following?

a. Beans and other green vegetables.
b. Wheat and chicken.
c. Tea and in the bones of fish (especially soft-boned sardines and salmon).
d. Coffee and grapes.
68. Fluorapatite replaces hydroxyapatite in tooth enamel which provides which of the following
benefits?
a. Fluorapatite is a whiter crystal and produces a more aesthetic appearance.
b. Creates a smoother tooth surface so that calculus build up will happen at a much slower
rate.
c. Fluorapatite is stain resistant.
d. Fluorapatite is thermodynamically more stable than apatite and resists acid dissolution
to a greater extent than hydroxyapatite.
69. An example of an antimicrobial that is in the bisbiguanide class is which of the following?
a. Chlorhexidine.
b. Thymol.
c. Triclosan.
d. Sodium lauryl sulphate.
70. An example of an antimicrobial that is in the essential oil class is which of the following?
a. Chlorhexidine.
b. Thymol.
c. Triclosan.
71. An example of an antimicrobial that is in the phenols class is which of the following?
a. Chlorhexidine.
b. Thymol.
c. Triclosan.
72. The most effective antimicrobial agent for oral use in a mouthwash to date is which of the
following?
a. Chlorhexidine.
b. Thymol.
c. Triclosan.
d. Phenol.
73. Polyols have been incorporated into sugar-free chewing gums to what advantage?
a. A reduction in the rate of dental caries.
b. A reduction in the frequency of acid attack on the enamel.
c. Encourages remineralisation.
Feedback
1. ANS: c
a. That elimination of the microbe should result in clinical improvement is one of Koch’s
postulates.
b. That a microbe should be present in sufficient numbers to initiate disease is one of Koch’s
postulates.
c. Correct. The following statement is not one of Koch’s postulates: Disease is considered
to be the outcome of the overall activity of the total plaque microflora, but this might be
relevant to the microbial aetiology of oral diseases.
d. That the microbe should produce relevant virulence factors is one of Koch’s postulates.
REF: Relationship of plaque bacteria to disease, p. 104
2. ANS: c
a. The specific plaque hypothesis has been proposed to relate plaque composition to oral
disease.
b. The non-specific plaque hypothesis has been proposed to relate plaque composition to
oral disease.
c. Correct. A homeostatic hypothesis has not been proposed.
d. The ecological plaque hypothesis has been proposed to relate plaque composition to oral
disease.
REF: Relationship of plaque bacteria to disease: contemporary perspectives, p. 104.
3. ANS: b
a. The specific plaque hypothesis proposes that disease is due to the action of a very limited
(specific) number of bacteria.
b. Correct. The specific plaque hypothesis proposed that only a few species out of the
diverse collection of organisms comprising the resident plaque microflora are actively
involved in disease.
c. The specific plaque hypothesis proposes that disease is due to the action of a very limited
(specific) number of bacteria.
d. A high antibody titre to the microbe is not part of the specific plaque hypothesis.
REF: Relationship of plaque bacteria to disease: contemporary perspectives, p. 104
4. ANS: c
a. That the microbe should generate high levels of specific antibodies is one of the Koch’s
postulates.
b. That the microbes should produce relevant virulence factors is one of the Koch’s
postulates.
c. Correct. The ecological plaque hypothesis proposes that the organisms associated with
disease may also be present at sound sites, but at levels too low to be clinically relevant,
and a change in local environmental conditions drives their growth and selection.
d. The fact that plaque-mediated diseases are essentially mixed culture (polymicrobial)
infections, but in which only certain species are able to predominate, is relevant but is
not the major concept behind the ecological plaque hypothesis.
REF: Relationship of plaque bacteria to disease: contemporary perspectives, p. 104
5. ANS: a
a. Correct. Longitudinal epidemiological surveys provide the most insight into the role of
plaque bacteria in dental disease as it can establish cause-and-effect relationships.
b. Observational design is not a survey design used to determine the role of plaque bacteria
in human disease.
c. Cross-sectional design can only determine associations of plaque bacteria in human
disease and not cause-and-effect relationships.
d. Prospective is not a survey design used to determine the role of plaque bacteria in human
disease.
REF: Relationship of plaque bacteria to disease: implications for study design, p. 105
6. ANS: c
a. Aggressive enamel destruction is not the definition of the caries process.
b. Destruction of the cementum is not the definition of the caries process.
c. Correct. The dental caries process is the localised destruction of the tissues of the tooth
by bacterial fermentation of dietary carbohydrates.
d. Demineralisation of the root surface is not the definition of the caries process.
REF: Dental caries, p. 106
7. ANS: d
a. Pit and fissure caries are not a major problem related to ageing.
b. Interproximal caries are not a major problem related to ageing.
c. Buccal-surface caries are not a major problem related to ageing.
d. Correct. Root-surface caries are an increasing problem due to gingival recession which
often accompanies increasing age exposing the vulnerable cementum to microbial
colonisation.
8. ANS: a
a. Correct. Cavities begin as small demineralised areas below the surface of the enamel.
b. Demineralisation of the cementum is not part of the initial caries lesion.
c. Small demineralised areas that penetrate through the enamel are not the first stage in
the development of the initial caries lesion.
d. The initial carious lesion is not necessarily seen interproximally.
9. ANS: b
a. Consumption of highly acid goods is not the cause of bacterial acid production seen in
enamel demineralisation, but can cause dental erosion.
b. Correct. Demineralisation of the enamel is caused by acids produced from the microbial
fermentation of dietary carbohydrates.
c. Limited use of dental floss is not the cause of acid production seen in enamel
demineralisation.
d. Dry mouth is not the cause of acid production seen in enamel demineralisation, but low
saliva flow will predispose patients to caries.
10. ANS: c
a. Cavitation is not a part of the initial carious lesion.
b. Gingival recession is not a part of the caries process.
c. Correct. The initial stages of caries are reversible and remineralisation can occur, particu-
larly in the presence of fluoride.
d. Further demineralisation does not normally occur in the presence of fluoride.
11. ANS: b
a. S. sanguinis has not been strongly associated with caries.
b. Correct. S. sobrinus is a member of the mutans streptococcus group and has been impli-
cated in dental caries.
c. S. salivarius is not linked to caries.
d. S. oralis is not linked to dental caries.
REF: Microbiology of enamel caries, pp. 107–110
12. ANS: c
a. Approximal surfaces are not the most caries-prone sites.
b. Buccal surfaces are not the most caries-prone sites.
c. Correct. Fissures on occlusal surfaces are the most caries-prone sites.
d. Lingual surfaces are not the most caries-prone sites.
REF: Microbiology of enamel caries, p. 108
13. ANS: d
a. Secondary caries, not rampant caries, is the term applied to caries that recur beneath and
around previous restorations.
b. Secondary caries, not periodic caries, is the term applied to caries that recur beneath and
c. Secondary caries, not bottle caries, is the term applied to caries that recur beneath and
d. Correct. Secondary caries describe the dental caries that recur beneath and around previ-
ous restorations.
14. ANS: b
a. The father is not the main source of mutans streptococci.
b. Correct. The mother is the main source of these bacteria.
c. Exposure to sugar is not a source of mutans streptococci, but it can promote colonisation
by mutans streptococci.
d. Grandparents are not the main source of mutans streptococci.
15. ANS: c
a. 60% of individuals aged 60 years or older have root caries or fillings.
b. 60% of individuals aged 60 years or older have root caries or fillings.
c. Correct. 60% of individuals aged 60 years or older have root caries or fillings.
d. 60% of individuals aged 60 years or older have root caries or fillings.
REF: Microbiology of root surface caries, pp. 110–111
16. ANS: b
a. Candida is not strongly linked to enamel dental caries.
b. Correct. Mutans streptococci and lactobacilli are both strongly linked to enamel dental
caries.
c. Actinomyces is not strongly linked with enamel caries.
d. Actinomyces is not strongly linked with enamel caries.
REF: Microbiology of enamel caries, pp. 107–111
17. ANS: c
a. Mutans streptococci, lactobacilli and Actinomyces have been linked most commonly with
root surface lesions.
b. Mutans streptococci, lactobacilli and Actinomyces have been linked most commonly with
c. Correct. Mutans streptococci, lactobacilli and Actinomyces have been linked most com-
monly with root surface lesions.
d. Mutans streptococci, lactobacilli and Actinomyces have been linked most commonly with
REF: Microbiology of root surface caries, pp. 110–112
18. ANS: b
a. Rapid sugar transport facilitates more rapid production of acid from dietary carbohydrates.
b. Correct. Cariogenic bacteria have a high tolerance of external low pH, enabling them to
survive and grow under acidic environmental conditions.
c. EPS contributes to the biofilm matrix and may localise acidic fermentation products.
d. IPS allows acid production to continue even in the absence of dietary carbohydrates.
REF: Pathogenic determinants of cariogenic bacteria, Table 6.4, pp. 114–115
19. ANS: c
a. Microflora does not become predominately aerobic, but is more anaerobic.
b. The pH becomes slightly alkaline.
c. Correct. In disease, the crevice becomes a pocket.
d. The temperature in the crevice/pocket actually increases.
REF: Ecology of the periodontal pocket: implications for plaque sampling, p. 118
20. ANS: a
a. Correct. In the sampling process, care has to be taken to preserve viability of obligately
anaerobic species.
b. Special care in sampling aerobic species is not necessary.
c. Special care in sampling Gram negative species is not necessary, though many of them
are obligately anaerobic.
d. Special care in sampling asaccharolytic bacteria is not necessary.
REF: Ecology of the periodontal pocket: implications for plaque sampling, Table 5.7,
pp. 118–119
21. ANS: c
a. The environment favours the growth of proteolytic and anaerobic species.
b. A decrease in temperature does not happen subgingivally—rather, the temperature
increases slightly.
c. Correct. Changes in subgingival region such as increases in GCF, pH and temperature
are all factors that promote the growth of bacteria implicated in periodontal disease.
d. Decrease in flow of GCF does not happen in periodontal disease—rather, there is an increase.
REF: Human studies, p. 119
22. ANS: c
a. Chronic periodontitis is one of the main types of periodontal diseases.
b. Gingival diseases are one of the main types of periodontal disease categories.
c. Correct. Acute periodontitis is not one of the 4 named types of periodontal disease.
d. The main types of periodontal disease are (a) gingival diseases, (b) chronic periodontitis,
(c) necrotising forms of periodontal diseases, and (d) aggressive periodontitis.
REF: Microbiology of periodontal diseases, p. 119
23. ANS: c
a. Chronic and aggressive periodontitis can be localised or generalised, and there can be modifiers
of chronic periodontitis such as diabetes, smoking, certain medications, and HIV infection.
b. Chronic and aggressive periodontitis can be localised or generalised, and there can be
modifiers of chronic periodontitis such as diabetes, smoking, certain medications, and
HIV infection.
c. Correct. Pneumonia is not typically a key modifier of chronic and aggressive periodontal
disease.
d. Chronic and aggressive periodontitis can be localised or generalised, and there can be
modifiers of chronic periodontitis such as diabetes, smoking, certain medications, and
HIV infection.
REF: Microbiology of periodontal disease, p. 119
24. ANS: c
a. Chronic marginal gingivitis is a non-specific host response to dental plaque involving the
gingival margins.
b. Chronic marginal gingivitis is a reversible inflammatory response to dental plaque involv-
ing the gingival margins.
c. Correct. Chronic gingivitis is reversible.
d. Chronic marginal gingivitis is an inflammatory response to dental plaque involving the
gingival margins.
REF: Gingivitis, p. 120
25. ANS: d
a. It is estimated that the whole dentate population is affected by gingivitis at some stage.
b. It is estimated that the whole dentate population is affected by gingivitis at some stage.
c. It is estimated that the whole dentate population is affected by gingivitis at some stage.
d. Correct. It is estimated that the whole dentate population is affected by gingivitis at
some stage.
26. ANS: d
a. Mal-occlusion is not the general reason for gingivitis to develop.
b. Concomitant medication is not the general reason for gingivitis to develop.
c. Co-existing systemic disease is not the general reason for gingivitis to develop.
d. Correct. Generally, gingivitis is regarded as resulting from a non-specific proliferation of
normal gingival crevice microflora due to poor oral hygiene.
27. ANS: c
a. Mal-occlusion does not generally play a role in gingivitis.
b. Sleep-apnoea does not generally play a role in gingivitis.
c. Correct. The clinical signs are exaggerated and the gingivae are more oedematous and
inflamed in individuals experiencing hormonal disturbances.
d. Rheumatoid arthritis does not play a role in gingivitis.
28. ANS: c
a. 10–20 fold increase in plaque mass is associated with the development of gingivitis.
b. A shift towards plaque dominated by anaerobic Gram negative bacteria is associated with
the development of gingivitis.
c. Correct. An increase in the carbohydrate balance in the diet is not associated with the
development of gingivitis.
d. Poor oral hygiene is associated with the development of gingivitis.
29. ANS: b
a. An increase in crevicular temperature does not have to precede the development of
periodontitis.
b. Correct. While it is accepted that not all gingivitis progresses to more serious forms of
periodontitis it is agreed upon that gingivitis must precede periodontitis.
c. Cariogenic shift in bacteria do not have to precede the development of periodontitis.
d. Hormonal disturbances do not have to precede the development of periodontitis.
30. ANS: a
a. Correct. Chronic periodontitis is the most common form of advanced periodontal disease
affecting the general population and a major cause of tooth loss after the age of 25 years.
b. Chronic periodontitis, not gingivitis, is the form of periodontal disease affecting the
general population and a major cause of tooth loss after age of 25.
c. Chronic periodontitis, not necrotising periodontitis, is the form of periodontal disease
affecting the general population and a major cause of tooth loss after age of 25.
d. Chronic periodontitis, not aggressive periodontitis, is the form of periodontal disease
affecting the general population and a major cause of tooth loss after age of 25.
REF: Chronic periodontitis, p. 120
31. ANS: b
a. In the USA, about one third of adults suffer from the disease at some time during their life.
b. Correct. In the USA, about one third of adults suffer from the disease at some time
during their life.
c. In the USA, about one third of adults suffer from the disease at some time during their
life.
d. In the USA, about one third of adults suffer from the disease at some time during their
life.
32. ANS: c
a. Loss of attachment from gingiva to root surface is involved in chronic periodontitis.
b. Potential inflammation of the periodontal ligament is involved in chronic periodontitis.
c. Correct. It is an increase in anaerobic bacteria in the gingival pocket that is implicated
in chronic periodontitis.
d. Bone loss is involved in chronic periodontitis.
33. ANS: b
a. Gingival hyperplasia does not necessarily predispose someone towards chronic
hyperplasia.
b. Correct. Overhanging restorations is a factor that can enhance plaque retention and
predispose someone towards chronic periodontitis.
c. Mal-occlusion does not necessarily predispose someone towards chronic periodontitis.
d. Toothbrush abrasion is not a factor in chronic periodontitis.
REF: Chronic periodontitis, pp. 120–121
34. ANS: c
a. Gram positive facultatively anaerobic bacteria are associated primarily with subgingival
health.
b. Gram negative facultatively anaerobic bacteria are not associated with initiation of
disease.
c. Correct. Gram negative obligate anaerobes are associated with gingival inflammation.
d. Spirochaetes are associated with a more severe disease state and appear later in the inflam-
matory process.
35. ANS: b
a. F. nucleatum is Gram negative.
b. Correct. P. micra is Gram positive.
c. P. intermedia is Gram negative.
d. P. gingivalis is Gram negative.
36. ANS: b
a. E. corrodens is generally associated with healthy sites.
b. Correct. P. gingivalis is found in deep periodontal pockets.
c. S. intermedius is generally associated with healthy sites.
d. C. gingivalis is generally not associated with deep periodontal pockets.
37. ANS: c
a. Directly targeting the putative pathogens is still consistent with the ecological plaque
hypothesis.
b. Stimulating saliva flow is consistent with the ecological plaque hypothesis.
c. Correct. Active vaccination against S. mutans is not consistent with the ecological plaque
hypothesis. Other bacteria with relevant traits would still be capable of causing caries.
d. The use of snacks with non-fermentable sweeteners is consistent with the ecological
plaque hypothesis.
REF: Re-evaluation of the microbial aetiology of dental caries, pp. 115–116
38. ANS: b
a. Gram positive anaerobic organisms do not play a significant role in chronic periodontitis.
b. Correct. An increase in GCF flow can provide a novel source of nutrients which could
enrich the growth of previously undetected species.
c. A mutation in endogenous species would not explain the emergence of previously un
detected species.
d. There is very little evidence that acquisition of pathogens from another person would
lead to detectable levels of an exogenous pathogen in a periodontal pocket.
39. ANS: a
a. Correct. NUG (and necrotizing ulcerative periodontitis) can be manifestations of under-
lying systemic problems such as HIV infection.
b. Chronic periodontitis is not associated with underlying systemic problems such as HIV
infection.
c. Juvenile periodontitis is not associated with underlying systemic problems such as HIV
infection.
d. Cancrum oris (noma) is not associated with underlying systemic problems such as HIV
infection and is linked more to malnutrition and a compromised immune system.
REF: Necrotising periodontal diseases, p. 123
40. ANS: c
a. Petechiae are not a characteristic of NUG.
b. Bleeding on probing is a universal characteristic of periodontal diseases.
c. Correct. NUG is characterised clinically by the formation of a grey pseudomembrane
on the gingivae which easily sloughs off revealing a bleeding area beneath it.
d. Excessive salivation is not a characteristic of periodontal diseases.
41. ANS: d
a. P. gingivalis is not particularly associated with localised aggressive periodontitis.
b. T. forsythia is not associated with localised aggressive periodontitis.
c. ‘Red complex’ bacteria are not associated with localised aggressive periodontitis.
d. Correct. A. actinomycetemcomitans is associated with localised forms of aggressive
periodontitis.
REF: Aggressive periodontitis, pp. 124–126
42. ANS: a
a. Correct. A fuso-spirochaetal complex of bacteria can be seen in smears of affected lesions.
b. P. nigrescens and P. gingivalis are not both associated with NUG lesions.
c. Spirochaetes are not the only bacteria present in these lesions.
d. Motile bacteria are not the only bacteria present in these lesions.
43. ANS: b
a. Chlorhexidine has not been reported to be effective in eliminating the fuso-spirochaetal
complex from infected sites.
b. Correct. Metronidazole is effective in eliminating the fuso-spirochaetal complex from
infected sites and thus is associated with rapid clinical improvement.
c. Penicillin is not used in the treatment of NUG.
d. Tetracycline therapy has not proven effective in the treatment of NUG.
44. ANS: a
a. Correct. Prostaglandins in GCF correlate with periodontal status and could act as predic-
tors of attachment loss.
b. Gingipains are bacterial virulence factors.
c. Leukotoxins are bacterial virulence factors.
d. Antibodies to the ‘red complex’ of bacteria have not been shown to correlate with attach-
ment loss.
REF: Pathogenic mechanisms in periodontal disease, pp. 128–130
45. ANS: c
a. Chronic periodontitis does not present with localised, rapid onset.
b. Necrotising periodontal disease presents with lesions spreading into the cheek, face and
neck causing extensive tissue loss.
c. Correct. Aggressive periodontitis is a rare condition that usually occurs in adolescents.
The disease appears to start around puberty, is more common in girls, with cases often
clustered in families, and with rapid loss of attachment. The disease shows some racial
predispositions, as it is slightly more common in people of West African and Asian origin.
d. Acute streptococcal gingivitis results in severe illness, but not periodontal involvement.
REF: Aggressive periodontitis, p. 125
46. ANS: c
a. Chlorhexidine plus root planing and scaling is an inadequate therapy for aggressive
periodontitis.
b. Metronidazole plus root planing and scaling is an inadequate therapy for aggressive
periodontitis.
c. Correct. The combination of metronidazole and amoxicillin has been found to be par-
ticularly effective when combined with scaling and root planing.
d. Tetracycline does not always lead to complete elimination of A. actinomycetemcomitans
from the pocket.
47. ANS: d
a. The damaged neutrophils in the majority of patients with aggressive periodontitis
produce decreased chemotaxis.
b. The damaged neutrophils in the majority of patients with aggressive periodontitis
produce decreased phagocytosis.
c. The damaged neutrophils in the majority of patients with aggressive periodontitis
produce increased superoxide radical production.
d. Correct. The damaged neutrophils in the majority of patients with aggressive periodon-
titis produce a variety of abnormalities including abnormal signal transduction
pathways.
48. ANS: a
a. Correct. Strains of A. actinomycetemcomitans produce a range of virulence factors, includ-
ing a powerful leukotoxin.
b. Gingipain is a virulence factor of P. gingivalis.
c. Lipoteichoic acid is present in the cell wall of some Gram positive bacteria.
d. A. actinomycetemcomitans does not produce hydrogen peroxide.
49. ANS: c
a. A. actinomycetemcomitans is linked to aggressive periodontitis.
b. Treponema species are associated with necrotising periodontal diseases.
c. Correct. P. intermedia is linked to pregnancy gingivitis.
d. A. odontolyticus is evident in healthy sites.
REF: Other periodontal diseases, p. 127
50. ANS: b
a. Acyclovir or penciclovir would be the antiviral drug effective against acute herpetic
gingivostomatitis.
b. Correct. Acyclovir or penciclovir would be the antiviral drug effective against acute
herpetic gingivostomatitis.
c. Acyclovir or penciclovir would be the antiviral drug effective against acute herpetic
gingivostomatitis.
d. Acyclovir or penciclovir would be the antiviral drug effective against acute herpetic
gingivostomatitis.
51. ANS: b
a. These are virulence factors associated with periodontal disease, and are not affected by
fluoride.
b. Correct. Glycolysis, IPS synthesis and sugar transport are inhibited by fluoride.
c. LPS production is not inhibited by fluoride.
d. Cell wall synthesis is not inhibited by fluoride.
REF: Fluoride, p. 138
52. ANS: b
a. Periodontal disease does not cause pancreatic inflammation to occur.
b. Correct. Periodontal pathogens may raise pro-inflammatory mediators that result in
insulin resistance and an increase in blood glucose, thereby predisposing individuals to
develop type 2 diabetes.
c. Periodontal disease increases blood glucose.
d. Periodontal disease increases insulin resistance.
53. ANS: b
a. There is no evidence to suggest that antibiotic therapy alone will improve glycaemic
control in a diabetic.
b. Correct. Mechanical treatment of periodontitis, when combined with antimicrobial
agents, can improve glycaemic control.
c. Evidence does not suggest that hydrogen peroxide combined with root planing will
improve glycaemic control in a diabetic.
d. There is no evidence to suggest that antiviral therapy will improve glycaemic control in
a diabetic.
54. ANS: b
a. Aspartame is an intense artificial sweetener.
b. Correct. Casein is a protein found in milk and is not an artificial sweetener.
c. Xylitol is an intense natural sweetener.
d. Saccharin is an intense artificial sweetener.
REF: Sugar substitutes, pp. 141–142
55. ANS: b
a. Cancrum oris affects young children.
b. Correct. Cancrum oris affects young children, although immunocompromised adults can
also be affected.
c. Cancrum oris affects young children.
d. Cancrum oris affects young children.
56. ANS: c
a. Noma is most common in Africa.
b. Noma is most common in Africa.
c. Correct. Noma is most common in Africa.
d. Noma is most common in Africa.
57. ANS: d
a. Approximately 200 000 children under 6 years of age contract noma each year.
b. Approximately 200 000 children under 6 years of age contract noma each year.
c. Approximately 200 000 children under 6 years of age contract noma each year.
d. Correct. Approximately 200 000 children under 6 years of age contract noma each year;
consequently, noma has been declared a priority by WHO.
58. ANS: b
a. Capsule is a bone resorbing factor involved in tissue damage.
b. Correct. Periodontal pathogens attach to and colonise on the subgingival tooth surface
through attachment mechanisms such as adhesins and fimbriae.
c. The production of protease obtains nutrients for multiplication and growth.
d. Leukotoxin is a mechanism in the evasion of host defences.
REF: Pathogenic mechanisms in periodontal disease, p. 130
59. ANS: c
a. LTA is present on Gram positive bacteria.
b. Ammonia can be cytotoxic but is not produced by P. gingivalis.
c. Correct. The gingipains of P. gingivalis can contribute to degradation of key host mol-
ecules, thereby deregulating the host response and promoting vascular permeability.
d. Leukotoxin is produced by A. actinomycetemcomitans.
60. ANS: d
a. Antibodies are present, but do not form the main defence strategy by the host against
periodontal pathogens.
b. Phagocytic cells such as neutrophils form the main defence strategy by the host against
c. Phagocytic cells such as neutrophils form the main defence strategy by the host against
d. Correct. Phagocytic cells such as neutrophils form the main defence strategy by the host
against periodontal pathogens.
61. ANS: a
a. Correct. Tissue-damaging enzymes produced by subgingival bacteria that may damage
tissue matrix molecules directly include hyaluronidase, chondroitin sulphatase and
glycylprolyl.
b. Microbial invasion of host tissues occurs in NUG, where there is superficial invasion
of the gingival connective tissues by spirochaetes; enzymes do not play a role in
that process.
c. Evasion and/or inactivation of host defences is a function of leukotoxin and the host
release of pro-inflammatory cytokines.
d. Multiplication of putagenic pathogens is aided by protease production, the development
of food chains, and an inhibitor production, such as bacteriocins.
62. ANS: b
a. Preventing an exogenous invasion of microbes is a function of the host defences.
b. Correct. For the establishment of disease, organisms must gain access to and adhere at
a susceptible site, multiply, overcome or evade the host defences and produce or induce
tissue damage.
c. Providing nutrients to the advancing front of the lesion is not part of disease
establishment.
d. Inducing suppresser T cells is a function of host defence evasion.
REF: Pathogenic synergism and periodontal disease, p. 132
63. ANS: a
a. Correct. Salivary tests for mutans streptococci and lactobacill are being considered as a
potential indicator for caries and not periodontal disease.
b. Sensitive and rapid molecular tests for putative pathogens are considered sensitive predic-
tors of future disease activity.
c. Enzyme detection in subgingival plaque is considered a sensitive predictor of future
disease activity.
d. Detection of inflammatory mediators in the GCF is considered a sensitive predictor of
future disease activity.
REF: Predictors of disease activity, p. 135
64. ANS: d
a. Evidence suggests that an association exists between periodontal disease and cardiovas-
cular disease.
b. Oral microorganisms, including periodontal pathogens, can cause aspiration pneumonia
in susceptible patients.
c. Pre-term labour has been associated with periodontal disease.
d. Correct. Hepatic disorders have not been associated with periodontal bacteria.
REF: Predictors of disease activity, pp. 136–137
65. ANS: c
a. Sealants are a dental caries treatment.
b. Antimicrobial oral rinse is a plaque control measure.
c. Correct. Debridement of the root surfaces is the most effective treatment for chronic
periodontitis.
d. Flossing is a supragingival plaque control measure.
REF: Approaches for controlling plaque-mediated diseases, p. 137
66. ANS: a
a. Correct. The optimum concentration for maximal protection against caries is approxi-
mately 1 part per million (1 ppm).
b. The optimum concentration for maximal protection against caries is approximately 1 part
per million (1 ppm).
c. The optimum concentration for maximal protection against caries is approximately 1 part
d. The optimum concentration for maximal protection against caries is approximately 1 part
67. ANS: c
a. Fluoride is found naturally in tea and in the bones of fish (especially soft-boned sardines
and salmon).
b. Fluoride is found naturally in tea and in the bones of fish (especially soft-boned sardines
and salmon).
c. Correct. Fluoride is found naturally in tea and in the bones of fish (especially soft-boned
sardines and salmon).
d. Fluoride is found naturally in tea and in the bones of fish (especially soft-boned sardines
and salmon).
68. ANS: d
a. Fluorapatite is invisible and does not create a white tooth surface.
b. Fluorapatite does not produce a smoother tooth surface.
c. Fluorapatite is not stain resistant.
d. Correct. Fluorapatite is thermodynamically more stable than apatite and resists acid
dissolution to a greater extent than hydroxyapatite.
69. ANS: a
a. Correct. Chlorhexidine is an antimicrobial that is in the bisbiguanide class.
b. Thymol is in the class of essential oils.
c. Triclosan is in the class of phenols.
d. Sodium lauryl sulphate is in the class of surfactants.
REF: Antimicrobial agents, pp. 140–141
70. ANS: b
a. Chlorhexidine is a bisbiguanide.
b. Correct. Thymol is an example of an antimicrobial that is in the essential oil class.
c. Triclosan is a phenol.
71. ANS: c
a. Chlorhexidine is a bisbiguanide.
b. Thymol is an example of an antimicrobial that is in the essential oil class.
c. Correct. Triclosan is an example of an antimicrobial that is in the phenol class.
72. ANS: a
a. Correct. Chlorhexidine is the most effective antimicrobial agent for oral use to date and
can be successfully formulated into a mouthrinse. This bisbiguanide has a broad spectrum
of activity against yeasts, fungi, and a wide range of Gram positive and Gram negative
bacteria.
b. Essential oils (menthol, thymol, eucalyptol, etc.) have been successfully formulated into
a mouthwash and shown to penetrate plaque biofilms, but are not as effective as
chlorhexidine.
c. Triclosan is the most commonly used antimicrobial agent in toothpastes but is not as
effective as chlorhexidine.
d. Triclosan is a phenol, the most commonly used antimicrobial agent in toothpastes, but
is not as effective as chlorhexidine.
REF: Antimicrobial agents, pp. 140, 141
73. ANS: d
a. Polyols have been incorporated into sugar-free chewing gums; the use of these products
three or more times a day can reduce the incidence of caries, by reducing the frequency
of acid attack on the enamel and by stimulating saliva flow, thereby encouraging
remineralisation.
b. Polyols have been incorporated into sugar-free chewing gums; the use of these products three
or more times a day can reduce the incidence of caries, by reducing the frequency of acid
attack on the enamel and by stimulating saliva flow, thereby encouraging remineralisation.
c. Polyols have been incorporated into sugar-free chewing gums; the use of these products
three or more times a day can reduce the incidence of caries, by reducing the frequency
of acid attack on the enamel and by stimulating saliva flow, thereby encouraging
remineralisation.
d. Correct. Polyols have been incorporated into sugar-free chewing gums; the use of these
products three or more times a day can reduce the incidence of caries, by reducing the
frequency of acid attack on the enamel and by stimulating saliva flow, thereby encouraging
remineralisation.
REF: Sugar substitutes, p. 141
C H A P T E R 7
Orofacial Bacterial Infections
Multiple Choice
1. Dental plaque is a causal factor in which of the following?
a. Periodontitis.
b. Angular cheilitis.
c. Ludwig’s angina.
d. Dry socket.
2. Studies have revealed that the types of bacteria isolated from orofacial infections reflect
a. Polymicrobial infections, with a wide spectrum of facultative bacteria and strictly anaero-
bic bacteria.
b. Obligately anaerobic bacteria only.
c. Gram positive anaerobic bacteria only.
d. Gram negative anaerobic bacteria only.
3. What is the primary source of nutrients for microorganisms isolated from orofacial infections?
a. Serum-derived proteins.
b. Gingival crevicular fluid (GCF)-derived proteins.
c. Saliva-derived proteins.
d. Proteins derived from the diet.
4. What is the most appropriate sampling technique for specimens with which to diagnose
orofacial infections?
a. Moist swabs placed immediately into phosphate-buffered saline (PBS).
b. Moist swab directly into reduced transport fluid.
c. Aspiration of pus by syringe.
d. Whole saliva.
5. What is a clinical feature of dry socket?

a. Xerostomia.
b. Bacterial sialadenitis.
c. Halitosis.
d. Pseudomembrane formation over socket.
6. Which is the bacterium most commonly isolated from cases of cervicofacial actinomycosis?
a. Actinomyces naeslundii.
b. Actinomyces actinomycetemcomitans.
c. Actinomyces bovis.
d. Actinomyces israelii.
101
102 7—Orofacial Bacterial Infections
7. Which of the following is a localised collection of bacteria, inflammatory cells, tissue break-
down products, serum-derived proteins and other organic material?
a. Periodontitis.
b. Abscess.
c. Gingivitis.
d. Cellulitis.
8. Inflammation into surrounding soft tissues from a dentoalveolar abscess is defined by which
of the following terms?
a. Periodontitis.
b. Abscess.
c. Lateral periodontal abscess.
d. Cellulitis.
9. What is the antibiotic of choice for treating cervicofacial actinomycosis?

a. Erythromycin.
b. Metronidazole.
c. Amoxicillin.
d. Clindamycin.
10. Which of the following make it difficult to determine the causative microorganisms in a
specific orofacial infection?
a. Local anatomical structures.
b. Sample contamination.
c. Septicaemia.
d. Pyrexia.
11. It is important that pus samples from orofacial infections be obtained via aspiration tech-
niques for which of the following reasons?
a. To include saliva for a full microbial sampling.
b. GCF can dilute and mask some microorganisms.
c. To protect oxygen sensitive anaerobes from oxygen.
d. To speed up the culture process.
12. Which of the following is the reason that identification of bacteria within orofacial infections
can take a number of days?
a. Time taken in plating the bacteria onto selective and non-selective agar plates.
b. Slow-growing nature of obligate anaerobes.
c. Lack of knowledge of optimal culture conditions.
d. Sample contamination with saliva.
13. The reduced in vitro antimicrobial susceptibility to penicillins and other antibiotics of bac-
teria recovered from orofacial infections is due to which of the following?
a. Contamination of cultures.
b. Emergence of antibiotic resistance.
c. Availability of nutrients and complementary enzymes.
d. Reduced activity of penicillins and other antibiotics.
7—Orofacial Bacterial Infections 103
14. Which of the following is a major reason for the emergence of penicillin resistance in oral
bacterial species encountered in the mouth?
a. Hypersensitivity to penicillin.
b. Catalase production by diverse microbial communities.
c. The emergence of beta-lactamase-producing bacteria.
d. Synergism to the incidence of clindamycin resistance.
15. Which of the following is a good alternative antibiotic agent for patients hypersensitive to
penicillins?
a. Cephalosporin.
b. Amoxicillin.
c. Erythromycin.
d. Ornidazole.
16. Which of the following represents an endotoxin found within infected root canals in symp-
tomatic teeth?
a. Lipoteichoic acid.
b. Macrophages.
c. Lipopolysaccharides.
d. Granulomatous material.
17. Which of the following terms is used to describe the pyogenic condition that affects the
teeth and supporting structures?
a. Dentoalveolar infection.
b. Stomatitis.
c. Chronic asymptomatic lesion.
d. Necrosis.
18. A lateral periodontal abscess can be differentiated from a dentoalveolar abscess by which of
the following?
a. Necrotic pulp is evident at the apex of the root.
b. The tooth has a vital pulp.
c. The tooth requires urgent antibiotic therapy.
d. The tooth does not have a vital pulp.
19. Which of the following is often the cause of a periodontal abscess?

a. Trauma to the tooth.
b. Coronal caries.
c. Foreign material in a periodontal pocket.
d. Root caries.
20. Recent research indicates that the complex polymicrobial community within endodontic
infections is similar to which of the following?
a. Acute dentoalveolar abscess.
c. Root caries.
d. Dry socket.
21. Which of the following is the most common cause of pulp death that accompanies an acute
dentoalveolar abscess?
a. Loss of supporting bone.
b. Advanced dental caries.
c. Trauma.
d. Periapical granuloma.
22. The pulp of a tooth may become necrotic due to loss of its blood supply as a result of which
of the following?
a. Period of chronic infection.
b. Loss of supporting bone.
c. Trauma.
d. Periodontitis.
23. What is the drug of choice to treat staphylococcal lymphadenitis?

a. Metronidazole.
b. Flucloxacillin.
c. Amoxycillin.
d. Tetracycline.
24. The onset of acute inflammation involved with acute dentoalveolar abscesses produces which
following characteristic sign or symptom?
a. Tooth mobility.
b. Severe pain.
c. Periapical granuloma.
d. Gingival inflammation.
25. The majority of cases of dentoalveolar abscesses can be managed successfully by which of
the following?
a. Intravenous antibiotics.
b. Prescribing oral antibiotic therapy.
c. Establishing a surgical drain.
d. Using antimicrobial rinses.
26. Animal studies have implicated which of the following as the causal organism of disseminat-
ing infection from an infected root canal to distant organs?
a. Porphyromonas gingivalis.
b. Olsenella profusa.
c. Treponema denticola.
d. Enterococcus faecalis.
27. Osteomyelitis in the jaw is rare, but is sometimes a consequence of which of the
following?
a. Radiotherapy.
b. Trauma.
c. Peri-implantitis.
d. Xerostomia.
28. Which of the following is the most frequently occurring orofacial bacterial infection?
a. Peri-implantitis.
b. Pericronitis.
c. Acute dentoalveolar abscess.
d. Dry socket.
29. The onset of raised body temperature and malaise associated with an acute dentoalveolar
abscess are a response to which of the following?
a. Methicillin resistant Staphylococcus aureus (MRSA).
b. Gram positive anaerobes.
c. Circulating inflammatory cytokines.
d. Macrophages.
30. Which of the following is an emerging form of periodontitis associated with tooth
replacement?
a. Bacterial sialadenitis.
b. Denture stomatitis.
c. Peri-implantitis.
d. Sjögren’s syndrome.
31. Inflammation of the soft tissues covering or immediately adjacent to the crown of a partially
erupted tooth is referred to as which of the following?
a. Peri-implantitis.
b. Alveolar osteitis.
c. Osteomyelitis.
d. Pericoronitis.
32. Facial lacerations involving the face, neck and scalp are most commonly infected with which
of the following?
a. ‘Red complex’ anaerobes.
b. Oral streptococci.
c. Staphylococcus epidermidis and Propionibacterium acnes.
d. Oral Gram positive anaerobes.
33. Irrigation with which of the following has been found to be beneficial in the treatment of
peri-implantitis?
a. A non-antimicrobial rinse/irrigation solution such as saliva.
b. Chlorhexidine.
c. Fluoride rinse.
d. A predominately alcohol-based solution.
34. Aggregates found in pus from sinuses generated in cervicofacial actinomycosis are referred
to as which of the following?
a. Sulphur granules.
b. Granulomas.
c. Macrophage–microbe aggregates.
d. Fibrinolysis.
35. Pericoronitis occurs due to which of the following?

a. Herpetic lesions.
b. Trauma.
c. Erupting lower third molar teeth in young adults.
d. Inflammation found in periodontal pockets.
36. Pericoronitis is most often caused by which of the following?

a. Over-instrumentation during an oral prophylaxis.
b. Infection in the space between the tooth and overlying soft tissue.
c. Overgrowth by anaerobic bacteria.
d. MRSA.
37. A recent simple test to determine the minimum inhibitory concentration (MIC) for a par-
ticular antibiotic on an agar plate is which of the following?
a. A-test.
b. E-test.
c. R-test.
d. MIC-test.
38. Which of the following is the term for inflammation of the salivary glands?
a. Stomatitis.
b. Xerostomia.
c. Pericoronitis.
d. Sialadenitis.
39. Sialadenitis within the parotid gland is usually due to the presence of which of the following?
a. Cheek bite trauma.
b. Underlying xerostomia.
c. Gingival inflammation.
d. Soft tissue abscess.
40. Sialadenitis within the parotid gland is usually due to the presence of underlying xerostomia
often associated with which of the following?
a. Pericoronitis.
b. Sjögren’s syndrome.
c. Gingival inflammation.
d. Alveolar osteitis.
41. Sialadenitis in the submandibular gland is most frequently secondary to which of the following?
a. Alveolar osteitis.
b. Pericoronitis.
c. Salivary stone blockage.
d. Stomatitis.
42. Pus from suppurative parotitis from should be collected by aspiration of the duct orifice in
order to minimise which of the following?
a. Antimicrobial resistance.
b. Recurrent parotitis.
c. Risk of sample contamination from the microflora in saliva.
d. Angular cheilitis.
43. Which of the following describes the condition that represents an area of inflammation that
is localised to the angles of the mouth?
a. Angular cheilitis.
b. Stomatitis.
c. Herpetic lesion.
d. Alveolar osteitis.
44. The inflammatory changes observed in angular cheilitis are associated with the presence of
Staphylococcus aureus or which of the following?
a. Aggregatibacter actinomycetemcomitans.
c. Candida spp.
d. Treponema spp.
45. Which is an example of an opportunistic infection caused by members of the Actinomyces

genus?
a. Denture stomatitis.
c. Cervicofacial actinomycosis.
d. Ludwig’s angina.
46. Which of the following is a specific condition in which a patient, usually a child, develops
a localised painful swelling of the facial lymph node?
a. Pericoronitis.
b. Lymphadenitis.
c. Cervicofacial actinomycosis.
d. Angular cheilitis.
Feedback
1. ANS: a
a. Correct. Dental plaque is a causal factor in periodontitis.
b. Dental plaque is not a causal factor of angular cheilitis.
c. Dental plaque is not a causal factor of Ludwig’s angina.
d. Dental plaque is not a causal factor of dry socket.
REF: Introduction, p. 149
2. ANS: a
a. Correct. Contemporary microbiological studies have revealed that the types of bacteria
recovered from orofacial dental infections reflect the wide spectrum of facultative and
strictly anaerobic bacteria and can be regarded as a polymicrobial infection.
b. The microflora found in orofacial dental infections is more diverse than just anaerobic
bacteria.
c. Gram positive bacilli are not only the predominant species involved in orofacial
infection.
d. Gram negative bacteria are not the only type of organism found in orofacial
infections.
3. ANS: a
a. Correct. The microflora use serum-derived proteins as their main source of nutrients.
b. GCF-derived proteins are the major source of proteins for bacteria in the inflamed peri-
odontal pocket, but not for orofacial infections.
c. Saliva-derived proteins may influence supragingival plaque, but not orofacial lesions.
d. Proteins from the diet have little impact on the oral microflora.
REF: Orofacial bacterial infections, p. 147
4. ANS: c
a. Swabs are not an efficient method of sampling, and sensitive anaerobic bacteria would
lose viability in PBS.
b. Swabs are not the most efficient method of sampling, though reduced transport fluid
would help preserve the viability of obligately anaerobic bacteria.
c. Correct. Aspiration of pus by syringe will minimise the risk of contamination and pre-
serve the viability of obligately anaerobic species.
d. Saliva will not be representative of the bacteria present in an orofacial lesion.
REF: Laboratory diagnosis, Figure 7.3, p. 148
5. ANS: c
a. Xerostomia is not a feature linked to dry socket.
b. Bacterial sialadenitis is not a feature linked to dry socket.
c. Correct. Dry socket often has pronounced halitosis.
d. The formation of a pseudomembrane is not linked to dry socket.
REF: Dry socket, pp. 154–155
6. ANS: d
a. A. naeslundii is isolated only occasionally from lesions.
b. A. actinomycetemcomitans belongs to the genus Aggregatibacter and is not associated with
actinomycosis.
c. A. bovis is isolated only occasionally from lesions.
d. Correct. A. israelii is associated with 90% of cases of actinomycosis.
REF: Cervicofacial actinomycosis, p. 157
7. ANS: b
a. Periodontitis is not a localised collection of bacteria, inflammatory cells, tissue breakdown
products, serum-derived proteins, and other organic material.
b. Correct. An abscess is a localised collection of bacteria, inflammatory cells, tissue break-
down products, serum-derived proteins and other organic material.
c. Gingivitis is not a localised collection of bacteria, inflammatory cells, tissue breakdown
products, serum-derived proteins and other organic material.
d. Cellulitis is the subsequent inflammation in the soft tissue which can lead to limited
localised muscle movement.
8. ANS: d
a. Periodontitis is not the result of the perforation of the surrounding bone.
b. An abscess is not the inflammation in surrounding soft tissues following the perforation
of the dentoalveolar process.
c. A lateral periodontal abscess does not perforate the bone spreading infection into sur-
rounding soft tissues.
d. Correct. Cellulitis occurs when a dentoalveolar abscess perforates the bone, which
permits spread of infection and subsequent inflammation into surrounding soft tissues.
9. ANS: c
a. Erythromycin can be used for patients who are hypersensitive to penicillins.
b. Metronidazole is not an antibiotic of choice for this condition.
c. Correct. Amoxicillin is the antibiotic of choice.
d. Clindamycin can be used for patients who are hypersensitive to penicillins.
REF: Cervicofacial actinomycosis, pp. 157–158
10. ANS: b
a. Local anatomical structures are not a problem associated with recovery of causative
microorganisms found from specific orofacial infections.
b. Correct. The microorganisms present in saliva can often pose a major problem with the
recovery of the causative microorganisms found in specific orofacial infections.
c. Septicaemia is a life-threatening condition where bacteria enter the bloodstream.
d. Pyrexia is an elevated temperature and does not interfere with microorganism isolation
and identification.
REF: Laboratory diagnosis, p. 148
11. ANS: c
a. Contamination is to be avoided, hence the aspiration technique protocol.
b. GCF does not play a role in obtaining samples of a purulent orofacial infection.
c. Correct. Samples of pus should be obtained by aspiration to minimise the risk of con-
tamination and protect oxygen sensitive anaerobes from atmospheric oxygen.
d. Identification of bacteria within orofacial infections can take a number of days due to
the slow-growing nature of many strict anaerobes. This factor limits the clinical benefit
of sampling such infections via aspiration or any other means.
12. ANS: b
a. The time taken in plating the bacteria is not the reason that identification of bacteria
within orofacial infections takes a number of days. The slow-growing nature of anaerobes
can make the identification of bacteria within orofacial infections take a number of days.
b. Correct. The slow-growing nature of anaerobes can make the identification of bacteria
within orofacial infections take a number of days.
c. Lack of knowledge of optimal culture methods is not the main reason that identification
of bacteria within orofacial infections takes a number of days. The slow-growing nature
of anaerobes can make the identification of bacteria within orofacial infections take a
number of days.
d. Sample contamination is not the main reason that identification of bacteria within oro-
facial infections takes a number of days. The slow-growing nature of anaerobes can make
the identification of bacteria within orofacial infections take a number of days. Sample
contamination can hamper accurate diagnosis.
13. ANS: b
a. The emergence of antibiotic resistance, not culture contamination, plays a role in causing
bacteria recovered from orofacial infections to have reduced in vitro antimicrobial sus-
ceptibility to penicillins and other antibiotics.
b. Correct. The emergence of antibiotic resistance is causing bacteria recovered from oro-
facial infections to have reduced in vitro antimicrobial susceptibility to penicillins and
other antibiotics.
c. The availability of nutrients and complementary enzymes do not play a role in causing
bacteria recovered from orofacial infections to have reduced in vitro antimicrobial sus-
ceptibility to penicillins and other antibiotics.
d. Reduced activity of penicillins and other antibiotics does not play a role in causing bac-
teria recovered from orofacial infections to have reduced in vitro antimicrobial
susceptibility.
REF: Antimicrobial susceptibility, p. 149
14. ANS: c
a. Patients sensitive to penicillin are not a major reason for the emergence of penicillin
resistance.
b. Catalase can break down hydrogen peroxide, not penicillin.
c. Correct. The widespread use of penicillin has contributed to the emergence of penicillin
resistance in oral bacterial species because it has been shown that the administration of
penicillin leads to the emergence of beta-lactamase-producing bacteria, especially Gram
negative bacilli, in sites such as the oropharynx.
d. The incidence of resistance to clindamycin is extremely low, even in countries such as
Germany and Japan, where this agent is frequently used to treat acute dental
infections.
REF: Principles of management, p. 150
15. ANS: c
a. Erythromycin is the alternative drug of choice for patients with hypersensitivity to
penicillins.
b. Erythromycin is the alternative drug of choice for patients with hypersensitivity to
penicillins.
c. Correct. Erythromycin is a good alternative agent for patients with hypersensitivity to
penicillins.
d. Erythromycin is a good alternative agent for patients with hypersensitivity to
penicillins.
REF: Principles of management, p. 150
16. ANS: c
a. Lipoteichoic acid is found in Gram positive bacteria, and is not an endotoxin.
b. Macrophages are phagocytic cells and not endotoxins.
c. Correct. In addition to the identification of bacteria, studies have quantified the presence
of endotoxins within root canals; higher levels of lipopolysaccharide were found in teeth
with clinical symptoms compared with asymptomatic teeth.
d. Granulomatous material is found at the apex of chronic root infections.
REF: Endodontic infection, p. 151
17. ANS: a
a. Correct. The term dentoalveolar infection can be used to describe pyogenic conditions
that affect the teeth and supporting structures.
b. Stomatitis is a general term used to describe an inflamed and sore mouth which may or
may not be associated with pus.
c. Chronic asymptomatic lesions indicate an asymptomatic, long-term (chronic) infection.
d. Necrosis is a term used to describe death of body tissue.
REF: Dentoalveolar infection, p. 151
18. ANS: b
a. Necrotic pulp is not evident at the apex of the root in a tooth with a lateral periodontal
abscess.
b. Correct. The lateral periodontal abscess can be differentiated from a dentoalveolar
abscess by the fact that it has a vital pulp.
c. Antibiotic therapy is rarely required.
d. A tooth with a lateral periodontal abscess has a vital pulp.
REF: Lateral periodontal abscess, p. 151
19. ANS: c
a. A periodontal abscess is not caused by trauma to the tooth.
b. Coronal caries do not cause a periodontal abscess.
c. Correct. The periodontal abscess develops as a result of the presence of foreign material
in an established periodontal pocket.
d. Root caries do not cause a periodontal abscess.
REF: Lateral periodontal abscess, p. 151
20. ANS: a
a. Correct. Recent research indicates that the complex polymicrobial community within
endodontic infections is similar to that found in dentoalveolar abscesses.
b. The microflora found in endodontic infections is not similar to angular cheilitis.
c. The microflora of root caries is not similar to endodontic infections.
d. The aetiology of dry socket is not fully understood.
21. ANS: b
a. Loss of supporting bone is not the cause of pulp death in an acute dentoalveolar
abscess.
b. Correct. Advanced dental caries are the most common cause of pulp death in an acute
dentoalveolar abscess.
c. On occasion, the pulp of a tooth may die due to loss of blood supply from trauma, but
it is not the most common cause of pulp death in an acute dentoalveolar abscess.
d. Periapical granuloma is not the cause of pulp death in an acute dentoalveolar
abscess.
REF: Acute dentoalveolar abscess, p. 151
22. ANS: c
a. A period of chronic infection is not a cause of pulp death that accompanies an acute
dentoalveolar abscess.
b. Loss of supporting bone is not a cause of pulp death that accompanies an acute dento
alveolar abscess.
c. Correct. Occasionally, the pulp of a tooth may become necrotic due to loss of its blood
supply as a result of trauma, such as a blow to the tooth.
d. Periodontitis is not a cause of pulp death that accompanies an acute dentoalveolar abscess.
23. ANS: b
a. Flucloxacillin is the drug of choice for staphylococcal lymphadenitis.
b. Correct. Flucloxacillin is the drug of choice for staphylococcal lymphadenitis.
c. Flucloxacillin is the drug of choice for staphylococcal lymphadenitis.
d. Flucloxacillin is the drug of choice for staphylococcal lymphadenitis.
REF: Staphylococcal lymphadenitis, p. 158
24. ANS: b
a. Tooth mobility is not an immediate sign of the onset of acute inflammation involved
with acute dentoalveolar abscesses.
b. Correct. The onset of acute inflammation involved with acute dentoalveolar abscesses
produces the characteristic symptom of severe pain.
c. Periapical granuloma, often asymptomatic, is not an immediate sign or symptom of the
onset of acute inflammation involved with acute dentoalveolar abscesses.
d. Gingival inflammation is not an immediate sign of the onset of acute inflammation
involved with acute dentoalveolar abscesses.
25. ANS: c
a. Intravenous antibiotics would not normally be used to manage the majority of cases of
dentoalveolar abscesses.
b. Oral antibiotics may be used adjunctively in the management of dentoalveolar abscesses.
c. Correct. The majority of cases of dentoalveolar abscesses can be managed successfully
by establishing a surgical drain alone.
d. Antimicrobial rinses alone would not be sufficient treatment for dentoalveolar abscesses.
26. ANS: c
a. Animal studies have not implicated P. gingivalis as the cause of disseminating infection
from the root canal to distant organs.
b. Animal studies have not implicated O. profusa as being the cause of disseminating infec-
tion from the root canal to distant organs.
c. Correct. Animal studies have implicated T. denticola as being the cause of disseminating
infection from the root canal to distant organs.
d. Animal studies have not implicated E. faecalis as being the cause of disseminating infec-
tion from the root canal to distant organs.
27. ANS: a
a. Correct. Radiotherapy, resulting in reduced vascularity, is associated with osteomyelitis.
b. Radiotherapy is associated with osteomyelitis.
c. Radiotherapy is associated with osteomyelitis.
d. Radiotherapy is associated with osteomyelitis.
REF: Osteomyelitis, p. 153
28. ANS: c
a. Acute dentoalveolar abscess is the most frequently occurring orofacial bacterial infection.
b. Acute dentoalveolar abscess is the most frequently occurring orofacial bacterial infection.
c. Correct. Acute dentoalveolar abscess is the most frequently occurring orofacial bacterial
infection.
d. Acute dentoalveolar abscess is the most frequently occurring orofacial bacterial infection.
29. ANS: c
a. MRSA is not associated with the onset of raised body temperature and malaise associated
with an acute dentoalveolar abscess.
b. Gram positive anaerobes are not associated with the onset of raised body temperature
and malaise associated with an acute dentoalveolar abscess.
c. Correct. The onset of raised body temperature and malaise associated with an acute
dentoalveolar abscess are a consequence of circulating inflammatory cytokines, inter-
leukins, and tumour necrosis factor in response to bacterial endotoxin.
d. Macrophages are not associated with the onset of raised body temperature and malaise
associated with an acute dentoalveolar abscess.
30. ANS: c
a. Bacterial sialadenitis is not an emerging form of periodontitis that is a direct consequence
of the increasing use of dental implants.
b. Denture stomatitis is not an emerging form of periodontitis that is a direct consequence
c. Correct. Peri-implantitis is an emerging form of periodontitis that is a direct conse-
quence of the increasing use of dental implants.
d. Sjögren’s syndrome is not an emerging form of periodontitis that is a direct consequence
REF: Peri-implantitis, p. 155
31. ANS: d
a. Peri-implantitis is not inflammation of the soft tissues covering or immediately adjacent
to the crown of a partially erupted tooth, but inflammation surrounding an implant.
b. Alveolar osteitis is not inflammation of the soft tissues covering or immediately adjacent
to the crown of a partially erupted tooth, but an inflammation of the alveolar bone typi-
cally occurring as a postoperative complication of tooth extraction.
c. Osteomyelitis is not inflammation of the soft tissues covering or immediately adjacent
to the crown of a partially erupted tooth, but an infection and inflammation of the bone
or bone marrow.
d. Correct. Inflammation of the soft tissues covering or immediately adjacent to the crown
of a partially erupted tooth is referred to as pericoronitis.
REF: Pericoronitis, p. 155
32. ANS: c
a. ‘Red complex’ anaerobes are associated with periodontitis rather than facial lacerations.
b. Oral streptococci are not associated with facial lacerations.
c. Correct. Facial lacerations are associated with members of the commensal skin micro-
flora, such as Staphylococcus epidermidis and Propionibacterium acnes.
d. Oral Gram positive anaerobes are not associated with facial lacerations.
REF: Facial lacerations, p. 158
33. ANS: b
a. A non-antimicrobial rinse/irrigation solution would not be effective in the treatment of
peri-implantitis. Treatment requires antimicrobial activity.
b. Correct. Irrigation with an antiseptic, such as chlorhexidine, has been found to be ben-
eficial in the treatment of peri-implantitis.
c. A fluoride rinse is not an effective approach for the treatment of peri-implantitis.
Treatment requires antimicrobial activity.
d. A predominately alcohol-based solution is not an accepted treatment of peri-implantitis.
Treatment requires antimicrobial activity.
REF: Peri-implantitis, p. 155
34. ANS: a
a. Correct. The aggregates are referred to as ‘sulphur granules’.
b. The aggregates are referred to as ‘sulphur granules’.
c. The aggregates are referred to as ‘sulphur granules’.
d. The aggregates are referred to as ‘sulphur granules’.
REF: Cervicofacial actinomycosis, pp. 157–158
35. ANS: c
a. Herpetic lesions are not the cause of pericoronitis.
b. Pericoronitis does not occur as a result of trauma; however, if the operculum is swollen,
it may prevent teeth from fully occluding and lead to pain and tissue trauma.
c. Correct. Pericoronitis occurs frequently in relation to erupting lower third molar teeth
in young adults.
d. Pericoronitis is not the inflammation found in periodontal pockets.
36. ANS: b
a. An oral prophylaxis is not a cause of pericoronitis.
b. Correct. Pericoronitis occurs fairly frequently and is due to infection in the space between
the tooth and overlying soft tissue.
c. Anaerobic bacteria are not necessarily the cause of pericoronitis.
d. MRSA is not the cause of pericoronitis.
37. ANS: b
a. The E-test allows direct reading of an antimicrobial MIC from an agar plate.
b. Correct. The E-test allows direct reading of an antimicrobial MIC from an agar plate.
c. The E-test allows direct reading of an antimicrobial MIC from an agar plate.
d. The E-test allows direct reading of an antimicrobial MIC from an agar plate.
REF: Antimicrobial susceptibility, Figure 7.5, pp. 149–150
38. ANS: d
a. Stomatitis refers to any inflammatory process affecting the mucous membranes of the
mouth and lips.
b. Xerostomia is a dry mouth as a result of a change in salivary flow or salivary
composition.
c. Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially
erupted tooth.
d. Correct. Sialadenitis is the term for inflammation of the salivary glands.
REF: Bacterial sialadenitis, p. 155
39. ANS: b
a. Sialadenitis within the parotid gland is not the result of trauma.
b. Correct. Sialadenitis within the parotid gland is often due to the presence of underlying
xerostomia.
c. Sialadenitis within the parotid gland may co-exist with gingival inflammation but it is
not the cause.
d. Sialadenitis within the parotid gland is not due to the presence of a soft-tissue abscess.
40. ANS: b
a. Pericoronitis is not associated with xerostomia and is not the cause of sialadenitis.
b. Correct. Sialadenitis within the parotid gland is usually due to the presence of underlying
xerostomia as a result of Sjögren’s syndrome.
c. Gingival inflammation is not associated with xerostomia and is not the cause of
sialadenitis.
d. Alveolar osteitis is not associated with xerostomia and is not the cause of sialadenitis.
41. ANS: c
a. Sialadenitis in the submandibular gland is secondary to blockage by a salivary stone, not
alveolar osteitis.
b. Sialadenitis in the submandibular gland is secondary to blockage by a salivary stone, not
pericoronitis.
c. Correct. Sialadenitis in the submandibular gland is most frequently secondary to block-
age by a salivary stone.
d. Stomatitis refers to any inflammatory process affecting the mucous membranes of the
mouth and lips.
42. ANS: c
a. Pus from suppurative sialadenitis should be collected by aspiration of the duct orifice to
avoid contamination from oral microflora.
b. Recurrent parotitis of childhood is relatively rare, but does occur. However, pus from
suppurative sialadenitis should be collected by aspiration of the duct orifice to avoid
contamination from oral microflora.
c. Correct. Pus from suppurative sialadenitis should be collected by aspiration of the duct
orifice in order to minimise the risk of sample contamination from the microflora found
in saliva.
d. Angular cheilitis, an inflammation localised to the angles of the mouth, is not associated
with suppurative parotitis. Pus from suppurative sialadenitis should be collected by aspira-
tion of the duct orifice to avoid contamination from oral microflora.
43. ANS: a
a. Correct. Angular cheilitis describes the condition that represents an area of inflammation
that is localised to the angles of the mouth.
b. Stomatitis refers to any inflammatory process affecting the mucous membranes of the
mouth and lips.
c. A herpetic lesion is a viral infection and could occur at a site similar to that of angular
cheilitis. However, angular cheilitis describes the condition that represents an area of
inflammation that is localised to the angles of the mouth.
d. Alveolar osteitis is inflammation of the alveolar bone, not soft tissue.
REF: Angular cheilitis, p. 156
44. ANS: c
a. The inflammatory changes are not associated with the presence of A.
actinomycetemcomitans.
b. The inflammatory changes are not associated with the presence of P. gingivalis.
c. Correct. The inflammatory changes are associated with the presence of staphylococci or
Candida, either alone or in combination.
d. The inflammatory changes seen with angular cheilitis are associated with the presence
of Treponema spp.
45. ANS: c
a. Denture stomatitis is caused by Candida spp.
b. The inflammatory changes associated with angular cheilitis are caused by Staphylococcus
aureus, MRSA, and Candida spp.
c. Correct. Cervicofacial actinomycosis is an example of an opportunistic infection caused
by members of the Actinomyces genus.
d. Ludwig’s angina is mainly associated with obligately anaerobic bacteria.
46. ANS: b
a. Pericoronitis involves soft-tissue swelling covering the crown of a partially erupted tooth.
b. Correct. Lymphadenitis is a specific condition in which a patient, usually a child, devel-
ops a localised painful swelling of the facial lymph node.
c. Cervicofacial actinomycosis presents as a submandibular swelling and is associated with
A. israelii.
d. Angular cheilitis is an area of inflammation localised to the angles of the mouth.
REF: Staphylococcal lymphadenitis, p. 158
C H A P T E R 8
Antimicrobial Prophylaxis
Multiple Choice
1. The empirical overuse of antibiotics has been accompanied by an enormous increase in the
emergence of microbial resistance; which of the following describes what impact that has
had on the use of antimicrobials?
a. Antiseptics are used as an alternative to antibiotics.
b. Antibiotics are used for shorter treatment courses.
c. Antibiotics are ineffective for many common diseases.
d. Antibiotics should never be used as they exacerbate bacterial resistance.
2. Which is the most common bacterium isolated from cases of infective endocarditis?
a. Streptococci.
b. Staphylococci.
c. Candida spp.
d. Enterococci.
3. Which of the following is not one of the four occasions when prophylactic antimicrobials
are indicated?
a. The risk of post-operative infection is high.
b. When wounds are contaminated with soil or dirt (e.g., after road traffic accidents) and
there is a risk of infection (e.g., Clostridium tetani).
c. To meet patient demand.
d. When a person’s defences against infection are compromised.
4. When do the majority of post-operative infections occur?

a. Within the first 12 hours.
b. Within the first 48 hours.
c. At the time of surgery.
d. Within the first 24 hours.
5. Endogenous, post-operative infection occurs most often when the surgery is done in which
of the following conditions?
a. Infection control procedures are compromised.
b. Patient presents with diabetes mellitus.
c. There is pre-existing periodontal disease.
d. The surgical site is already infected with patient’s own pathogenic bacteria.
118
8—Antimicrobial Prophylaxis 119
6. Exogenous wound infections in the oral cavity arise from microorganisms being introduced
due to which of the following?
a. Lack of thorough hand washing.
b. Lack of sterile field.
c. Lack of use of antiseptics in preparation of operation site.
d. Non-sterile instruments.
7. Infections can occur weeks or months after surgery and are due to which of the following?
a. Patients introducing bacteria into the surgical site.
b. Latent effect following use of non-sterile instruments.
c. Microorganisms remaining quiescent and then reactivating.
d. The patient becomes immunocompromised.
8. A number of mechanisms could explain how prophylactic antimicrobials work and include
a. They form complexes that increase phagocytosis.
b. They make conditions unfavourable to microbial growth.
c. They eliminate opportunistic microorganisms.
d. They are partially effective against environmental microorganisms.
9. The necessity of prophylactic antimicrobial use with oral surgical operations has been ques-
tioned due to which of the following?
a. Endogenous infections are not affected by antimicrobials.
b. Low incidence of post-operative infections.
c. High antimicrobial effect of saliva.
d. Increased vasculature in the oral cavity enhances surgical wound healing.
10. One important factor to consider when selecting the antimicrobial agent is that it should be
able to do which of the following?
a. Eliminate all microorganisms associated with post-surgical infection.
b. Have a long half-life.
c. Penetrate the tissues concerned.
d. Have a short half-life to enhance clearance.
11. The ability of a pre- or post-operative antimicrobial to penetrate which of the following is
important in the selection process?
a. Mucosal surfaces.
b. Bone.
c. Soft tissue.
d. Dentin.
12. Which of the following agents do not adequately penetrate bone?

a. Clindamycin.
b. Metronidazole.
c. Amoxicillin.
d. Cephalosporins.
120 8—Antimicrobial Prophylaxis
13. Maximum concentrations of an appropriate antimicrobial agent in the oral skeletal structures
should occur within which of the following time frames?
a. 1 hour.
b. 6 hours.
c. 12 hours.
d. 24 hours.
14. The current consensus of opinion concerning the rate of post-operative infectious complica-
tions supports which of the following protocols?
a. Prophylactic antimicrobial agents should be used with prudence.
b. Routine prophylactic antimicrobial use is a justifiable practice.
c. It is better not to be conservative with the use of antimicrobials.
d. Antimicrobial prophylaxis cannot be justified.
15. Double-blind randomized trials support which of the following approaches to the use of
antibiotics during third molar surgery?
a. Antimicrobial agents are effective for patients with poor oral hygiene undergoing third
molar surgery.
b. Antimicrobial agents are effective given before and after third molar extractions for
patients who have a very heavy biofilm present throughout the mouth.
c. Antimicrobial agents have shown no statistically significant effect on post-operative
problems most often associated with third molar extraction.
d. Antimicrobial agents are effective given pre- and post-operatively for third molar extrac-
tions in patients who present with pericoronitis.
16. Which is the principal oral streptococcal species isolated from cases of infective endocarditis?
a. S. sobrinus.
b. S. salivarius.
c. S. anginosus.
d. S. sanguinis.
17. The rhamnose-rich adhesin found on streptococci that binds them to platelets and induces
aggregation is known as what?
a. LTA.
b. PRP.
c. PAAP.
d. GTF.
18. A risk assessment and review of the literature reveals which of the following with regard to
the link between dental treatment and the proven cases of infected joint replacements?
a. There is a significant relationship between dental treatment and proven cases of infected
joint replacements.
b. A paucity of proven evidence shows there is no relationship between dental treatment
and infected joint replacements.
c. There is an inconclusive link between dental treatment and proven cases of infected joint
replacements.
d. Ongoing research is needed to determine the role that dental treatment plays in post-
operative infected joint replacements.
19. An infected hip prosthesis requiring another surgical replacement operation has what per-
centage chance of being successful?
a. 25%.
b. 40%.
c. 75%.
d. 90%.
20. Amoxicillin is a poor choice in joint replacement as a prophylactic antimicrobial for which
of the following reasons?
a. It has a relatively short half-life.
b. It has not been proven to be effective in penetrating bone tissue.
c. It may rarely cause a severe intestinal condition.
d. It may result in the development of oral thrush if used for prolonged periods of time.
21. Which of the following expresses the conclusions of double-blind, placebo-controlled, ran-
domized trials on the use of a prophylactic antimicrobial prior to and following implant
placement?
a. Of significant clinical benefit.
b. Equivocal but probably not of use.
c. Strong negative relationship to implant success.
d. Necessary for insurance purposes.
22. A potentially life-threatening post-operative infection following dental procedures is which

of the following?
a. Cardiac arrhythmia.
b. Angina pectoris.
c. Cardiac dysrhythmia.
d. Infective endocarditis.
23. Which of the following best describes the likelihood of a link between infective endocarditis
and dentistry?
a. Controversial.
b. Confirmed.
c. Being studied.
d. Depends upon the patients presenting condition.
24. Even when prolonged intravenous antibiotics are given promptly to kill the infecting agent,
endocarditis still has a high mortality rate of which of the following?.
a. 5–10%.
b. 10–20%.
c. 25–40%.
d. 50–60%.
25. Which of the following is the term used to describe bacteria in the blood stream during
dental treatment?
a. Angina.
b. Septicaemia.
c. Blood poisoning.
d. Bacteraemia.
26. If a patient experiences bacteraemia during a dental treatment and the bacteria attach to the
endothelium of the heart, which of the following is likely to occur?
a. A heart attack.
b. Inflammation.
c. A thrombolytic event.
d. Sepsis.
27. The rise in the number of people developing infective endocarditis due to staphylococci is
likely due to which of the following?
a. Use of unsterile needles by intravenous drug addicts.
b. Increase in periodontal disease.
c. Increase in the number of people who are undergoing subgingival scaling.
28. Which of the following conditions does not make patients as susceptible to infective endo-
carditis as the others?
a. Acquired valvular damage.
b. Valvular insufficiency.
c. Structural congenital heart disease.
d. Cardiomyopathy.
Feedback
1. ANS: c
a. Antiseptics are not a good alternative to antibiotics as they are commonly not effective
against resistant forms of bacteria.
b. Shorter treatment times may be ineffectual.
c. Correct. The empirical overuse of antibiotics has been accompanied by an enormous
increase in the emergence of microbial resistance; this has made some antimicrobials
ineffective for the treatment of some common diseases.
d. They should be used judiciously as they may exacerbate bacterial resistance.
REF: Antimicrobial agents, p. 160
2. ANS: b
a. Staphylococci are the most commonly isolated bacterium from cases of infective
endocarditis.
b. Correct. Staphylococci are the most commonly isolated bacterium from cases of infective
endocarditis.
c. Staphylococci are the most commonly isolated bacterium from cases of infective
endocarditis.
d. Staphylococci are the most commonly isolated bacterium from cases of infective
endocarditis.
REF: Infective endocarditis, Table 8.1, pp. 163–164
3. ANS: c
a. The use of prophylactic antimicrobials is appropriate when the risk of post-operative
infection is high.
b. The use of prophylactic antimicrobials is appropriate when wounds are contaminated
with soil or dirt (e.g., after road traffic accidents) and there is a risk of infection (e.g.,
Clostridium tetani).
c. Correct. To meet patient demand is not an appropriate medical rationale to recommend
or prescribe a medication.
d. The use of prophylactic antimicrobials is appropriate when a person’s defences against
infection are compromised.
REF: Antimicrobial agents, p. 160
4. ANS: c
a. The majority of post-operative infections occur at the time of surgery.
b. The majority of post-operative infections occur at the time of surgery.
c. Correct. The majority of post-operative infections occur at the time of surgery.
d. The majority of post-operative infections occur at the time of surgery.
REF: When does post-operative infection occur?, pp. 160–161
5. ANS: d
a. The most common cause of endogenous post-operative infection is not necessarily com-
promised infection control procedures.
b. The most common cause of endogenous post-operative infection is not necessarily when
a surgical procedure is done on a patient with diabetes mellitus.
c. The most common cause of endogenous post-operative infection is not necessarily when
there is pre-existing periodontal disease.
d. Correct. The most common time when endogenous post-operative infection occurs is
when the surgery is done on a site already infected with the person’s own pathogenic
microflora.
REF: When does post-operative infection occur?, p. 161
6. ANS: d
a. Lack of thorough hand washing is not necessarily a source of exogenous contamination.
b. Lack of sterile field is not necessarily a source of exogenous contamination.
c. Lack of use of antiseptics in preparation of operation site is not necessarily a source of
exogenous contamination.
d. Correct. Exogenous wound infections arise from microorganisms being introduced into
the mouth from a source outside the oral cavity and are usually caused by poor aseptic
technique or by non-sterile instruments.
7. ANS: c
a. Patients introducing bacteria into the surgical site is not necessarily how late infections
occur.
b. The use of non-sterile instruments would not be the cause of late infections.
c. Correct. Late infections can occur weeks or months after the operation and are due to
the reactivation of microorganisms that have remained quiescent within the site.
d. A patient becoming immunocompromised is not the cause of the occurrence of a late
infection.
8. ANS: a
a. Correct. Antimicrobials can attach to the surface of the microorganisms and form com-
plexes that increase phagocytosis, and could be an explanation as to how prophylactic
antimicrobials work.
b. Making conditions unfavourable to microbial growth would not necessarily explain how
prophylactic antimicrobials work.
c. Eliminating opportunistic microorganisms would not necessarily explain how prophylac-
tic antimicrobials work.
d. This statement is not a mechanism to explain how prophylactic antibiotics work.
REF: How does pre-surgical antimicrobial prophylaxis work?, p. 161
9. ANS: b
a. Endogenous infections, determined by the level of pre-surgical microflora, may or may
not support the use of prophylactic antimicrobials.
b. Correct. With oral surgical operations where the incidence of post-operative infection
is very low there is the question as to whether antimicrobial prophylaxis is necessary at
all.
c. Saliva does not have a high anti-microbial effect.
d. Increased vasculature in the oral cavity enhances surgical wound healing but may not
effectively deal with microbial attack.
REF: Antimicrobial prophylaxis for oral surgery, p. 162
10. ANS: c
a. It is not possible for any anti-microbial to totally eliminate all micro-organisms associated
with post-surgical infection.
b. An antimicrobial’s specific half-life may have no impact on the selection of the antimi-
crobial agent to be used.
c. Correct. One important factor to consider when selecting the antimicrobial agent is its
ability to penetrate the tissues concerned.
d. A short half-life would reduce the effectiveness of an antibiotic.
11. ANS: b
a. Bone is the most important tissue when it comes to the selection of an appropriate
antimicrobial agent, not mucosal surfaces.
b. Correct. One important factor to consider when selecting the antimicrobial agent is that
it should be able to penetrate the tissues concerned and in particular bone.
c. Bone is the most important tissue when it comes to the selection of an appropriate
antimicrobial, not soft tissue.
d. Bone is the most important tissue when it comes to the selection of an appropriate
antimicrobial, not dentin.
12. ANS: c
a. Clindamycin penetrates bone well.
b. Metronidazole penetrates bone well.
c. Correct. Amoxicillin does not penetrate bone well.
d. Cephalosporins penetrate bone well.
13. ANS: a
a. Correct. Most antimicrobial agents that penetrate bone do so rapidly in the oral skeletal
structures usually attaining maximal concentrations within one hour.
b. Most antimicrobial agents that penetrate bone do so rapidly in the oral skeletal structures
usually attaining maximal concentrations within one hour.
c. Most antimicrobial agents that penetrate bone do so rapidly in the oral skeletal structures
d. Most antimicrobial agents that penetrate bone do so rapidly in the oral skeletal structures
14. ANS: d
a. The current consensus of opinion is that the rate of post-operative infectious complica-
tions is so low that antimicrobial prophylaxis cannot be justified and would not affect the
outcome.
b. The current consensus of opinion is that the rate of post-operative infectious complica-
outcome.
c. The current consensus of opinion is that the rate of post-operative infectious complica-
outcome.
d. Correct. The current consensus of opinion is that the rate of post-operative infectious
complications is so low that antimicrobial prophylaxis cannot be justified and would not
affect the outcome.
REF: Antimicrobial prophylaxis for oral surgery, p. 162
15. ANS: c
a. There has been no statistically significant evidence that antimicrobial agents given before
and after third molar extraction are of clinical benefit.
b. There has been no statistically significant evidence that antimicrobial agents given before
c. Correct. There have been nine double-blind randomized trials of a variety of prophylactic
antimicrobial agents given before and after third molar surgery. All of these trials have
come to the same conclusion that antimicrobial agents have no statistically significant
effect on swelling, pain, trismus or post-operative infection.
d. There has been no statistically significant evidence that antimicrobial agents given before
REF: Third molar surgery, p. 162
16. ANS: d
a. Strep. sanguinis is the most commonly isolated streptococcal species isolated from cases
of infective endocarditis.
b. Strep. sanguinis is the most commonly isolated streptococcal species isolated from cases
c. Strep. sanguinis is the most commonly isolated streptococcal species isolated from cases
d. Correct. Strep. sanguinis is the most commonly isolated streptococcal species isolated
from cases of infective endocarditis.
REF: Infective endocarditis, Table 8.1, p. 164
17. ANS: a
a. LTA is lipoteichoic acid, and is found on the bacterial surface, but is not involved in
platelet aggregation.
b. PRP is a proline-rich rich peptide found in saliva.
c. Correct. PAAP is platelet aggregating protein.
d. GTF is a glucosyltransferase which makes glucan as part of the plaque matrix.
REF: Infective endocarditis, p. 164
18. ANS: b
a. A risk assessment and review of the literature reveals a paucity of proven cases where
infected joint replacement prostheses have been linked with dental treatment.
b. Correct. A risk assessment and review of the literature reveals a paucity of proven cases
where infected joint replacement prostheses have been linked with dental treatment.
c. A risk assessment and review of the literature reveals a paucity of proven cases where
d. A risk assessment and review of the literature reveals a paucity of proven cases where
REF: Joint replacement, p. 162
19. ANS: a
a. Correct. An infected hip prosthesis would require another surgical replacement operation
and has an approximately 25% chance of being successful, thus a person has only a 25%
chance of being able to satisfactorily walk again.
b. No; a person with an infected hip has a 25% chance of being able to walk satisfactorily
again.
c. No; a person with an infected hip has a 25% chance of being able to walk satisfactorily
again.
d. No; a person with an infected hip has a 25% chance of being able to walk satisfactorily
again.
20. ANS: b
a. Amoxicillin is not an appropriate choice as a prophylactic antimicrobial in joint replace-
ment because it not been proven to be effective in penetrating bone.
b. Correct. Amoxicillin is a poor choice in this particular circumstance as it has not been
proven to be effective in penetrating bone.
c. Amoxicillin is a poor choice in this particular circumstance as it has not been proven to
be effective in penetrating bone.
d. Amoxicillin is a poor choice in this particular circumstance as it has not been proven to
be effective in penetrating bone.
21. ANS: b
a. At least nine substantial double-blind placebo controlled randomized trials on the use of
prophylactic antimicrobials and implant placement have found, at best, equivocal results.
b. Correct. There have now been at least nine substantial double-blind placebo controlled
randomized trials on the use of prophylactic antimicrobials and implant placement that
find their use at best equivocal, but ‘probably not of use’.
c. At least nine substantial double-blind placebo controlled randomized trials on the use of
prophylactic antimicrobials and implant placement have found, at best, equivocal results.
d. Insurance does not dictate the use of prophylactic antimicrobials for implant placement
procedures.
REF: Dental implants, pp. 162–163
22. ANS: d
a. Cardiac arrhythmia is not a post-operative infection.
b. Angina pectoris is not a post-operative infection.
c. Cardiac dysrhythmia is not a post-operative infection.
d. Correct. One potential post-operative infection following dental procedures that could
be serious and life-threatening is infective endocarditis.
REF: Oral surgery where the consequences of post-operative infection are potentially
serious, p. 163
23. ANS: a
a. Correct. The link between this infection and dentistry is highly controversial, as is the
use of antimicrobial prophylaxis to prevent this condition.
b. The link between this infection and dentistry is highly controversial, as is the use of
antimicrobial prophylaxis to prevent this condition.
c. The link between this infection and dentistry is highly controversial, as is the use of
d. The link between this infection and dentistry is highly controversial, as is the use of
REF: Antimicrobial prophylaxis against infective endocarditis, p. 165
24. ANS: c
a. Even when prolonged intravenous antibiotics are given promptly to kill the infecting
agent, endocarditis still has a high mortality rate of 25–40%.
b. Even when prolonged intravenous antibiotics are given promptly to kill the infecting
c. Correct. Even when prolonged intravenous antibiotics are given promptly to kill the
infecting agent, endocarditis still has a high mortality rate of 25–40%.
d. Even when prolonged intravenous antibiotics are given promptly to kill the infecting
25. ANS: d
a. Angina is chest pain due to ischaemia of the heart muscle.
b. Septicaemia is a potentially fatal whole-body inflammation caused by severe infection.
c. Blood poisoning, sepsis, is a potentially fatal whole-body inflammation caused by severe
infection.
d. Correct. Bacteraemia is the term used when bacteria enter the blood stream.
26. ANS: b
a. Bacteraemias do not increase the risk of heart attacks.
b. Correct. If bacteria enter the blood stream they can cause inflammation of the heart
endothelium from which infective endocarditis can ensue.
c. Bacteraemias do not increase the risk of thrombolytic events.
d. Sepsis is not likely to occur subsequent to bacteraemia from dental treatment.
27. ANS: a
a. Correct. The rise in the number of people developing infective endocarditis due to
staphylococci is probably due to use of unsterile needles by intravenous drug addicts.
b. The rise in the number of people developing infective endocarditis due to staphylococci
is unrelated to an increase in periodontal disease.
c. The rise in the number of people developing infective endocarditis due to staphylococci
is unrelated to subgingival scaling procedures.
d. The rise in the number of people developing infective endocarditis due to staphylococci
is unrelated to poor oral hygiene.
28. ANS: b
a. There are four groups of patients who are particularly susceptible to infective endocarditis;
these are those with acquired valvular damage, structural congenital heart disease, valve
replacements and cardiomyopathy.
b. Correct. Patients with valvular insufficiency are not among the susceptible groups.
c. There are four groups of patients who are particularly susceptible to infective endocarditis;
d. There are four groups of patients who are particularly susceptible to infective endocarditis;
REF: Antimicrobial prophylaxis against infective endocarditis, p. 165
C H A P T E R 9
Oral Fungal Infections
Multiple Choice
1. Which one of the following fungal genera is considered to be a normal resident in the oral
cavity of healthy individuals?
a. Saccharomyces.
b. Candida.
c. Geotrichum.
d. Cryptococcus.
2. When conditions in the mouth favour the proliferation of Candida, which one of the fol-
lowing will most likely occur?
a. Salivary flow reduces.
b. Dental caries are initiated.
c. Oral candidosis may develop.
d. Dental plaque levels increase.
3. The term Candida originates from the Latin word candidus, meaning which of the following?
a. Disease.
b. Inflammation.
c. White.
d. Fungi.
4. Which of the following is generally the most prevalent Candida species recovered from the
human mouth in both commensal state and cases of oral candidosis?
a. Candida glabrata.
b. Candida tropicalis.
c. Candida albicans.
d. Candida guilliermondii.
5. Which one of the following is a factor most likely to be associated with promoting colonisa-
tion of Candida in the oral cavity?
a. Antibiotic resistance.
b. Sloughing of epithelial cells from the oral mucosa.
c. Non-specific adherence process.
d. Ability to release cytokines.
6. Which one of the following host factors is not associated with the development of oral
candidosis?
a. Reduced salivary flow.
b. The wearing of a denture.
c. The receipt of a broad-spectrum antibiotic.
d. Increased salivary flow.
130
9—Oral Fungal Infections 131
7. Which one of the following is a key virulence factor of C. albicans?

a. Beta-lactamase production.
b. Ability to secrete hydrolytic enzymes.
c. Production of endotoxins.
d. Growth of C. albicans in a yeast form only.
8. C. albicans has the ability to grow in several morphological states including which one of
the following?
a. Spirochaetes.
b. Periplasmic flagella.
c. Cystatins.
d. Hyphae.
9. Destruction of host tissues by Candida may be facilitated by which one of the following?
a. Presence of iron-free lactoferrin.
b. Salivary peroxidase enzymes.
c. Presence of defensins.
d. Release of hydrolytic enzymes.
10. One pathological effect of secreted aspartyl proteinases (SAPs) is due to which of the
following?
a. Enhanced degradation of dietary sugars.
b. An ability to degrade host extracellular matrix proteins.
c. An ability to kill competing bacteria in the oral cavity.
d. An ability to degrade phospholipids in host cell membranes.
11. Phospholipases are enzymes that hydrolyse phospholipids into which of the following?
a. Formate.
b. Fatty acids.
c. Lactic acids.
d. Amino acids.
12. A high incidence of oral candidosis is found primarily in which of the following patient
populations?
a. Patients with high caries rates.
b. Cases of cervicofacial actinomycosis.
c. Patients who are human immunodeficiency virus (HIV) positive and suffering from
acquired immunodeficiency syndrome.
d. Patients who suffer from herpes simplex virus infection.
13. Four distinct primary oral candidoses are frequently described based on which of the
following?
a. Pyrexia.
b. Clinical presentation.
c. Xerostomia.
d. Halitosis.
132 9—Oral Fungal Infections
14. Acute erythematous candidosis is characterised by the presence of which of the following?
a. Lichen planus.
b. Pseudomembranes.
c. Submandibular swelling.
d. Painful reddened patches.
15. Acute erythematous candidosis is most frequently associated with the administration of a
broad-spectrum antibiotic, and particularly if the patient also uses which one of the
following?
a. Antimicrobial rinse.
b. Warm salt water rinse.
c. Vinegar rinse.
d. Steroid inhaler.
16. Broad spectrum antibiotics decrease the bacterial community within the oral cavity, poten-
tially resulting in which of the following?
a. Formation of granulation tissue.
b. Suppurative parotitis.
c. An increase in the number of Candida.
d. Inflammation of the salivary glands.
17. A patient with chronic hyperplastic candidosis is most likely to be which one of the
following?
a. On antibiotic therapy.
b. A smoker.
c. Using an antimicrobial rinse.
d. Suffering from periodontal disease.
18. When left untreated, chronic hyperplastic candidosis can progress to dysplasia and, subse-
quently, which of the following?
a. Oral cancer.
b. Lichen planus.
c. Periodontal disease.
d. Herpes simplex virus infection.
19. Chronic hyperplastic candidosis can occur at any site on the oral mucosa, but is most fre-
quently encountered as bilateral white patches in which of the following areas?
a. Vestibular mucosa.
b. Vermillion border.
c. Dorsum of the tongue.
d. Buccal commissure regions.
20. Chronic hyperplastic candidosis presents as two lesional types: homogeneous lesions that are
smooth and white, which contrast with heterogeneous lesions, which appear as which of the
following?
a. Smooth and glossy.
b. Nodular or speckled.
c. Inflamed.
d. Areas of pseudomembrane development.
21. Which of the following types of chronic hyperplastic candidosis are more prone to malignant
transformation?
a. Heterogeneous.
b. Symmetrical.
c. Homogeneous.
d. Erythematous.
22. In addition to the primary forms of oral candidosis, which one of the following may be
secondary Candida-associated lesions?
a. Herpes simplex type 1 (HSV-1) infection.
b. Periodontal infection.
c. Angular cheilitis.
d. Lichen planus.
23. Angular cheilitis characteristically presents as erythematous lesions located at which of these
locations in the oral cavity?
b. Dorsum of the tongue.
c. Corners of the mouth.
d. Vermillion border.
24. Median rhomboid glossitis is seen as a symmetrical shaped area located in which of the
following areas in the oral cavity?
b. Vermillion border.
c. Corners of the mouth.
d. Dorsum of the tongue.
25. The key predisposing factor to a number of relatively rare congenital conditions associated
with chronic mucocutaneous candidosis centre on which of the following?
a. HSV-1 infection.
b. History of smoking.
c. Impaired cellular immunity.
d. Diabetes.
26. There are a wide variety of phenotypic methods routinely used to identify isolated Candida
including which one of the following?
a. Pulsed field gel electrophoresis.
b. Random amplified polymorphic DNA.
c. Biochemical profiling.
d. Inter-repeat sequence amplification.
27. Oral candidoses are opportunistic infections and as such arise when which one of the fol-
lowing occurs?
a. Host debilitation.
b. Development of antifungal resistance by colonising Candida.
c. Bacterial numbers increase in the oral cavity.
d. Infection with herpes simplex virus.
28. Undiagnosed or poorly controlled diabetes is a recognised predisposing factor to oral can-
didosis and therefore assessment of which of the following may be required?
a. Bilirubin.
b. Blood glucose.
c. Albumin.
d. Serum activity of alanine aminotransferase (ALT).
29. Which one of the following is a reason that in comparison to antibiotics, the development
of new antifungal agents has been relatively limited?
a. Difficulties of antifungal susceptibility testing.
b. Difficulty in identifying suitable fungal targets that are absent from host cells.
c. Relative costs associated with antifungal production.
d. Broad spectrum antibiotics effective against bacteria also tend to inhibit fungi.
30. Which of the following has been used as a systemic antifungal therapy for treating primary
forms of oral candidosis?
a. Nystatin.
b. Clotrimazole.
c. 5-Flucytosine.
d. Miconazole.
31. Enhanced occurrence of which one of the following is a reason that has contributed to greater
incidence of candidoses?
a. HSV-1 infection.
b. Oral cancer.
c. Immunosuppressive therapies.
d. Use of dental implants.
32. An example of a host predisposing factor leading to oral candidosis is which one of the
following?
a. Use of steroid inhalers.
b. Use of antiviral therapy.
c. Use of antimicrobial mouth rinses.
d. Herpes simplex virus infection.
33. In denture wearers who have chronic erythematous candidosis which of the following is
paramount to the management of this condition?
a. Improvement of denture hygiene.
b. Reducing carbohydrate intake.
c. Antibiotic therapy.
d. Reducing alcohol consumption.
34. Which one of the following is an antimicrobial peptide that is largely specific to the mouth
and has anti-candidal activity?
a. Defensins.
b. Mucins.
c. Histatins.
d. Transferrins.
Feedback
1. ANS: b
a. Saccharomyces are fungi that are not frequently encountered in the mouth of healthy
individuals.
b. Correct. Candida are fungi frequently encountered in the mouths of healthy individuals,
and as such are considered to be normal residents in the oral cavity.
c. Geotrichum are fungi that are not frequently encountered in the mouths of healthy
individuals.
d. Cryptococcus are fungi that are not frequently encountered in the mouths of healthy
individuals.
REF: Pathogenic Candida species, p. 166
2. ANS: c
a. A reduced salivary flow may promote Candida proliferation but does not follow increased
Candida proliferation.
b. Dental caries do not occur as a result of increased Candida numbers.
c. Correct. While Candida species are normally harmless, when conditions in the mouth
alter to favour proliferation of Candida, oral candidosis can occur.
d. Dental plaque is mainly comprised of bacteria and as such its levels are not necessarily
affected by conditions promoting Candida growth.
REF: Candida virulence factors, p. 167
3. ANS: c
a. The term Candida originates from the Latin word candidus, which means white, not
disease.
b. The term Candida originates from the Latin word candidus, which means white, not
inflammation.
c. Correct. The term Candida originates from the Latin word candidus, meaning white.
d. The term Candida originates from the Latin word candidus, which means white, not
fungi.
4. ANS: c
a. C. albicans not C. glabrata is the most prevalent Candida species recovered from the
human mouth.
b. C. albicans not C. tropicalis is the most prevalent Candida species recovered from the
human mouth, in both commensal state and cases of oral candidosis.
c. Correct. Generally, the most prevalent Candida species recovered from the human mouth
in both commensal state and cases of oral candidosis is C. albicans.
d. C. albicans not C. guilliermondii is the most prevalent Candida species recovered from the
human mouth in both commensal state and cases of oral candidosis.
5. ANS: c
a. Antibiotic resistance is not a factor that generally promotes Candida colonisation of the
oral cavity.
b. Sloughing of epithelial cells from the oral mucosa actually is a host defence mechanism
that promotes removal of Candida from the oral cavity.
c. Correct. The non-specific adherence process is a factor that allows Candida to initially
adhere to surfaces in the oral cavity.
d. The ability to release cytokines is not a factor that promotes Candida colonisation of the
oral cavity.
6. ANS: d
a. Reduced salivary flow is a host factor contributing to oral candidosis.
b. The wearing of a denture is associated with promoting Candida colonisation of the oral
cavity and may promote oral candidosis.
c. Receipt of a broad-spectrum antibiotic lowers bacterial numbers and can contribute to
the development of oral candidosis.
d. Correct. Increased salivary flow can lower Candida numbers by promoting their physical
removal from oral surfaces.
7. ANS: b
a. Beta-lactamase production is not a virulence factor of C. albicans.
b. Correct. One of the key virulence factors of C. albicans is its ability to secrete hydrolytic
enzymes that damage host cells.
c. Production of endotoxins is not a key virulence factor of C. albicans.
d. Growth of Candida in a yeast form is not a virulence factor of C. albicans.
8. ANS: d
a. Spirochaetes are a class of bacteria partly defined by their characteristic coiled cellular
morphology; it is not a Candida morphology.
b. Periplasmic flagella are appendages formed on the surfaces of certain bacteria.
c. Cystatins are a family of cysteine protease inhibitors and not a Candida morphology.
d. Correct. C. albicans has the ability to grow as hyphae.
REF: Morphology, p. 168
9. ANS: d
a. Destruction of host tissues by Candida may be facilitated by release of hydrolytic enzymes
into the local environment, not by the presence of iron-free lactoferrin.
b. The presence of salivary peroxidase enzymes is not a factor of host tissue destruction by
Candida.
c. Destruction of host tissues by Candida is not facilitated by the presence of defensins.
d. Correct. Destruction of host tissues by Candida may be facilitated by release of hydrolytic
enzymes by Candida into the local environment.
REF: Hydrolytic enzymes, p. 168
10. ANS: b
a. Proteinases do not hydrolyse sugars and this is therefore not a factor in virulence.
b. Correct. The exact role of secreted aspartyl proteinases (SAPs) in virulence remains
unclear; however, their ability to degrade host extracellular matrix proteins is thought to
be a pathogenic factor.
c. The role of secreted aspartyl proteinases (SAPs) in virulence appears related to their
ability to degrade host extracellular matrix proteins. These SAPs do not have the ability
to kill competing bacteria in the oral cavity.
d. Degradation of phospholipids in host cell membranes is mediated by phospholipases and
not SAPs.
REF: Secreted aspartyl proteinases (SAPs), p. 168
11. ANS: b
a. Phospholipases are enzymes that hydrolyse phospholipids not into formate, but into fatty
acids.
b. Correct. Phospholipases are enzymes that hydrolyse phospholipids into fatty acids.
c. Phospholipases are enzymes that hydrolyse phospholipids not into lactic acids, but into
fatty acids.
d. Phospholipases are enzymes that hydrolyse phospholipids not into amino acids, but into
fatty acids.
REF: Phospholipases, p. 168
12. ANS: c
a. Dental caries are not associated with incidences of oral candidosis.
b. Oral candidosis incidence is not associated with cervicofacial actinomycosis.
c. Correct. High incidence of oral candidosis is found in HIV-positive individuals and
those suffering from acquired immunodeficiency syndrome.
d. Patients who suffer from herpes simplex virus infection are not at increased risk of oral
candidosis.
REF: Oral candidosis, p. 169
13. ANS: b
a. Four distinct, primary oral candidoses are frequently described, based not upon the pres-
ence of pyrexia, but on clinical presentation.
b. Correct. Oral candidosis is not a single entity and four distinct primary oral candidoses
are frequently described based on clinical presentation.
c. Four distinct primary oral candidoses are frequently described, based upon clinical pres-
entation, not on the presence of xerostomia.
d. Four distinct primary oral candidoses are frequently described, based upon clinical pres-
entation, not on the presence of halitosis.
14. ANS: d
a. Lichen planus appears on the oral mucosa mostly as white lesions; it is a condition that
is not thought to be caused by Candida.
b. Pseudomembranous candidosis is a form of oral candidosis that presents as white plaque-
like pseudomembranes.
c. Acute erythematous candidosis is not characterised by submandibular swelling.
d. Correct. Acute erythematous candidosis is characterised by the presence of painful red-
dened patches on the oral mucosa, typically on the dorsum of the tongue.
REF: Acute erythematous candidosis, pp. 169–170
15. ANS: d
a. Acute erythematous candidosis is not exacerbated by the use of an antimicrobial rinse.
b. A warm salt water rinse does not exacerbate acute erythematous candidosis.
c. Acute erythematous candidosis is most frequently associated with the administration of
a broad spectrum antibiotic, but not with an adjunctive vinegar rinse.
d. Correct. Acute erythematous candidosis is most frequently associated with the admin-
istration of a broad spectrum antibiotic, particularly if the patient also uses a steroid
inhaler.
REF: Acute erythematous candidosis, Table 9.3, pp. 169–171
16. ANS: c
a. It is believed that the antibiotic decreases the bacterial community within the oral micro-
flora, which may result in an increase in Candida, not in the formation of granulation
tissue.
b. It is believed that the antibiotic decreases the bacterial community within the oral micro-
flora, which may result in an increase in Candida, but not in suppurative parotitis.
c. Correct. It is believed that the antibiotic decreases the bacterial community within the
oral microflora, allowing Candida numbers to increase due to reduced competition.
d. It is believed that the antibiotic decreases the bacterial community within the oral micro-
flora, which does not result in inflammation of the salivary glands.
REF: Acute erythematous candidosis, p. 171
17. ANS: b
a. A patient with chronic hyperplastic candidosis is not necessarily on antibiotic therapy.
b. Correct. A representative patient with chronic hyperplastic candidosis is often a middle-
aged smoker.
c. A representative patient with chronic hyperplastic candidosis is not necessarily using an
antimicrobial rinse.
d. A patient with chronic hyperplastic candidosis is not necessarily also suffering from peri-
odontal disease.
REF: Chronic hyperplastic candidosis, p. 171
18. ANS: a
a. Correct. If left untreated, some cases of chronic hyperplastic candidosis (5–10%) progress
to exhibit dysplasia with subsequent development of oral cancer.
b. Chronic hyperplastic candidosis will not develop into lichen planus.
c. Chronic hyperplastic candidosis if left untreated can subsequently develop into oral
cancer and not periodontal disease.
d. Chronic hyperplastic candidosis is generally asymptomatic and if left untreated does not
develop into herpes simplex virus infection.
19. ANS: d
a. Chronic hyperplastic candidosis can occur at any site on the oral mucosa but is most
frequently encountered as bilateral white patches in the buccal commissure regions, not
the vestibular border.
b. Chronic hyperplastic candidosis can occur at any site on the oral mucosa but is most
frequently encountered as bilateral white patches in the buccal commissure regions, not
the vermillion border.
c. Chronic hyperplastic candidosis can occur at any site on the oral mucosa and most com-
monly in the buccal commissure regions.
d. Correct. Chronic hyperplastic candidosis can occur at any site on the oral mucosa but is
most frequently encountered as bilateral white patches in the buccal commissure regions.
20. ANS: b
a. Heterogeneous lesions appear as areas of erythema, giving a nodular or speckled appear-
ance, not smooth and glossy.
b. Correct. Heterogeneous lesions appear as areas of erythema, giving a nodular or speckled
appearance.
c. Heterogeneous lesions appear as areas of erythema, giving a nodular or speckled appear-
ance, but not necessarily inflamed.
d. Heterogeneous lesions appear as areas of erythema, giving a nodular or speckled appear-
ance, but not as areas of pseudomembrane development.
21. ANS: a
a. Correct. Heterogeneous lesions are more prone to malignant transformation.
b. The shape of the chronic hyperplastic candidosis lesion is not indicative of a malignant
formation.
c. Of the lesion types of chronic hyperplastic candidosis, the homogeneous lesions are less
prone to malignant transformation compared with heterogeneous lesions.
d. Of the lesion types of oral candidosis, erythematous lesions are not more prone to malig-
nant transformation.
22. ANS: c
a. Candida-associated lesions do not include those caused by HSV-1.
b. Pseudomembranous candidosis is a primary form of Candida infection.
c. Correct. In addition to the primary forms of oral candidosis described, other Candida-
associated lesions are recognised and include conditions such as angular cheilitis.
d. Candida-associated lesions do not include lichen planus.
REF: Other secondary forms of oral candidosis, p. 171
23. ANS: c
a. Angular cheilitis does not characteristically present as erythematous lesions in the ves-
tibular mucosal area.
b. Angular cheilitis does not characteristically present as erythematous lesions on the
dorsum of the tongue.
c. Correct. Angular cheilitis characteristically presents as erythematous lesions at the
corners of the mouth.
d. Angular cheilitis characteristically presents as erythematous lesions at the vermillion
border.
24. ANS: d
a. Median rhomboid glossitis is seen as a symmetrical shaped area in the midline of the
dorsum of the tongue and not at the vestibular mucosa.
b. Median rhomboid glossitis is seen as a symmetrical shaped area on the midline of the
dorsum of the tongue and not at the vermillion border.
c. Median rhomboid glossitis is seen as a symmetrical shaped area on the midline of the
dorsum of the tongue and not at the corners of the mouth.
d. Correct. Median rhomboid glossitis is seen as a symmetrical shaped area located in the
midline of the dorsum of the tongue.
REF: Median rhomboid glossitis, p. 171
25. ANS: c
a. A number of relatively rare congenital conditions are associated with chronic mucocuta-
neous candidosis and the key predisposing factor would appear not to centre on a history
of HSV-1 but on impaired cellular immunity.
b. A number of relatively rare congenital conditions are associated with chronic mucocuta-
neous candidosis and the key predisposing factor would not appear to centre on smoking
history, but on impaired cellular immunity.
c. Correct. A number of relatively rare congenital conditions are associated with chronic
mucocutaneous candidosis and the key predisposing factor would appear to centre on
impaired cellular immunity.
d. A number of relatively rare congenital conditions are associated with chronic mucocuta-
neous candidosis and the key predisposing factor would appear not to centre on a history
of diabetes but on impaired cellular immunity.
REF: Chronic mucocutaneous candidosis, pp. 171–172
26. ANS: c
a. Pulsed field gel electrophoresis is a genotypic method largely reserved for epidemiological
investigations in research of oral candidosis.
b. Random amplified polymorphic DNA is a genotypic method largely reserved for epide-
miological investigations in research of oral candidosis.
c. Correct. Biochemical profiling is a phenotypic approach often used to identify Candida
isolates.
d. Inter-repeat sequence amplification is a genotypic method that can be used for epidemio-
logical investigations.
REF: Summary, p. 176
27. ANS: a
a. Correct. Opportunistic infections generally arise when the host becomes weakened or
debilitated thus impeding normal host defences.
b. Acquisition of resistance to antifungal agents does not lead to initiation of opportunistic
infection.
c. Oral candidosis is a fungal infection and therefore does not occur when bacterial numbers
increase.
d. Herpes simplex virus infection is not implicated in opportunistic infection by Candida.
REF: Management of oral candidosis, p. 176
28. ANS: b
a. Bilirubin is not a diagnostic test used to assess diabetes.
b. Correct. Undiagnosed or poorly controlled diabetes is a recognised predisposing factor
to oral candidosis and therefore assessment of blood glucose may be required.
c. Albumin is not a diagnostic test used to assess diabetes.
d. Serum activity of ALT is not a diagnostic test used to assess diabetes.
29. ANS: b
a. Difficulty of testing technique is not a reason that the development of antifungal agents
has been relatively limited.
b. Correct. Since fungi are eukaryotic cells they share many characteristics with mammalian
cells; as such, problems do arise in identifying suitable fungal targets that are absent from
host cells.
c. Relative cost of antifungal development compared with those of antibiotics is not the
reason for comparatively limited antifungal development.
d. Antibiotics targeting bacteria do not tend to be active against fungi.
REF: Antifungal intervention, p. 176
30. ANS: c
a. Nystatin is a topical antifungal agent.
b. Clotrimazole is a topical antifungal agent.
c. Correct. 5-Flucytosine is a systemic antifungal agent.
d. Miconazole is a topical antifungal agent.
REF: Polyene antifungals, Table 9.5, p. 177
31. ANS: c
a. It is not an increase in HSV-1 that has driven the significant advances in developing
methods to identify Candida.
b. It is not an increase in oral cancer that has driven the significant advances in developing
methods to identify Candida.
c. Correct. Increasing use of immunosuppressive therapy has enhanced the prevalence of
candidoses.
d. The increased use of dental implants is not associated with higher incidence of
candidosis.
REF: Chapter summary, p. 179
32. ANS: a
a. Correct. Use of steroid inhalers is a predisposing factor for oral candidosis.
b. Receipt of antiviral therapy is not a predisposing factor for oral candidosis.
c. The use of antimicrobial mouth rinses is not a predisposing factor for oral candidosis.
d. Herpes simplex virus infection is not a predisposing factor for oral candidosis.
33. ANS: a
a. Correct. In denture wearers who have chronic erythematous candidosis, improvement
of denture hygiene is paramount to management of this condition.
b. Reducing carbohydrate intake is not necessarily paramount to management of this
condition.
c. Antibiotic therapy in denture wearers who have chronic erythematous candidosis is not
necessarily paramount to management of this condition.
d. Reducing alcohol consumption is not necessarily paramount to management of this
condition.
34. ANS: c
a. Defensins have anti-candidal activity but are not necessarily specific to the mouth.
b. Mucins have anti-candidal activity but are not necessarily specific to the mouth.
c. Correct. Histatins are antimicrobial peptides largely specific to the mouth and have
anti-candidal activity.
d. Transferrins have anti-candidal activity but are not necessarily specific to the mouth.
REF: Host response to oral candidosis, p. 172

C H A P T E R 10
Orofacial Viral Infections
Multiple Choice
1. Which of the following is the estimated percentage of adults who harbour viruses that have
been acquired as a result of prior infection?
a. 60%.
b. 10%.
c. 45%.
d. 90%.
2. Which of the following is the principal basis for the development of the antiviral drugs that
are currently available?
a. Virus assembly.
b. Viral replication.
c. Protein synthesis.
d. Adsorption.
3. Which of the following has contributed to the difficulty in designing effective antiviral drug
therapies?
a. Viral replication.
b. Intracellular nature of infection.
c. Protein synthesis.
d. Cell membrane structure.
4. What is the approximate size of viruses?

a. 5–50 nm.
b. 100–300 nm.
c. 400–600 nm.
d. 650–850 nm.
5. Which of the following is a weakness of electron microscopy for use as a diagnostic technique?
a. High specificity.
b. Low sensitivity.
c. Low specificity.
d. High sensitivity.
6. The development of which of the following was a milestone in antiviral therapy, representing
the first true specific antiviral agent?
a. Atazanavir.
b. Lopinavar.
c. Aciclovir.
d. Nexavir.
143
144 10—Orofacial Viral Infections
7. Aciclovir is a nucleoside analogue drug that has activity against which of the following
members of the herpes group of viruses?
a. Epstein–Barr virus.
b. Cytomegalovirus.
c. Kaposi’s sarcoma herpes virus.
d. Herpes simplex type-1 (HSV-1).
8. Which of the following is the primary mechanism of action for aciclovir?

a. Virus assembly.
b. Inhibition of viral DNA synthesis.
c. Blocking viral replication.
d. Destruction of the viral cell membrane.
9. Which of the following is the Greek meaning of the name herpes?

a. Slow.
b. To creep.
c. Prolong.
d. Rapid.
10. Which of the following represents the prevalence/incidence of a primary infection with
HSV-1 in the population in the Western world?
a. Never.
b. Universally.
c. Infrequently.
d. Often.
11. Which of the following is the acronym for Kaposi’s sarcoma herpes virus?
a. HSV-1.
b. HCMV.
c. EBV.
d. HHV-8.
12. Which is the appropriate agent of choice for a patient who presents with herpetic gingivitis
diagnostic for HSV-1?
a. Amoxicillin.
b. Aciclovir.
c. Chlorhexidine.
d. Polymixin.
13. Regardless of the use of an antiviral agent, HSV-1 is not eliminated from the body following
resolution of the acute symptoms and the virus remains within the tissues in which of the
following states?
a. Prodromal.
b. Resistant.
c. Latent.
d. Active.
10—Orofacial Viral Infections 145
14. What is the approximate incidence of recurrent episodes of HSV-1?

a. 25%.
b. 100%.
c. 40%.
d. 75%.
15. Reactivation of HSV-1 characteristically produces herpes labialis, known more commonly
as which of the following?
a. Lip sore.
b. Cold sore.
c. Mucosal lesion.
d. Oral blister.
16. Traditionally, it has been thought that reactivated HSV-1 migrated to the peripheral tissues
of the lips or face from which of the following?
a. Hypoglossal nerve.
b. Trigeminal ganglion.
c. Zygomatic nerve.
d. Buccal nerve.
17. The prodromal symptom of herpes labialis (a tingle or burning sensation) originates on
a. Buccal mucosa.
b. Gingival margin.
c. Attached gingiva.
d. Vermillion border of lips.
18. Approximately what percentage of herpes labialis episodes have no prodromal stage and the
lesion initiates as vesicles?
a. 10%.
b. 25%.
c. 50%.
d. 90%.
19. Which of the following is so characteristic of herpes labialis that diagnosis is based on this
symptom alone?
a. Gingivostomatitis.
b. Vesiculobullous lesions.
c. Vesicles that rupture and crust over.
d. Pyrexia.
20. Which of the following predisposes susceptible individuals to an episode of herpes

labialis?
a. Poor nutrition.
b. Toothbrush abrasion.
c. Pre-existing gingivitis.
d. Sunlight.
21. Individuals with severe or frequent recurrences of herpes labialis can benefit from the pro-
phylactic use of which of the following?
a. Antimicrobial rinse.
b. Stannous fluoride rinse.
c. Ganciclovir.
d. Systemic aciclovir.
22. It is also recognised that latent HSV-1 is asymptomatic and is shed at least once a month
in the saliva in what percentage of the population?
a. 25%.
b. 10%.
c. 70%.
d. 50%.
23. Varicella zoster virus (VZV) primary infection occurs most frequently in childhood causing
a. Whooping cough.
b. Chickenpox.
c. Respiratory infection.
d. Pinkeye.
24. Reactivation of latent VZV in sensory nerve ganglia produces the clinical condition of herpes
zoster, which is more commonly described as which of the following?
a. Shingles.
b. Cold sores.
c. Hand, foot and mouth disease.
d. Glandular fever.
25. Epstein–Barr virus (EBV) has been associated with a number of infections that affect the
orofacial region including which of the following?
a. Oropharyngeal candidiasis.
b. Infectious mononucleosis.
c. Parotitis.
d. Sialadenitis.
26. The onset of a painful throat and submandibular lymphadenopathy, accompanied by fine
petechial haemorrhages in the hard and soft palate, is evident in which of the following
conditions?
a. Acute upper respiratory infection.
b. Meningitis.
c. Infectious mononucleosis.
d. Cytomegalovirus infection.
27. Characteristically, which of the following presents as a corrugated white lesion on the lateral
border of the tongue?
a. Aphthous ulcer.
b. Hairy leukoplakia.
c. Median rhomboid glossitis.
d. Lichen planus.
28. An aggressive tumour of the jaw associated with the Epstein-Barr virus (EBV) oncogenic
virus is which of the following?
a. Hodgkins lymphoma.
b. Burkitt’s lymphoma.
c. Basal cell carcinoma.
d. Non-Hodgkins lymphoma.
29. Human herpes virus 8 (HHV-8) is believed to be the aetiological agent of which of the
following?
a. Human papillomavirus.
b. Kaposi’s sarcoma.
c. Human immunodeficiency virus.
d. Severe acute respiratory syndrome virus (SARS).
30. The diagnosis of hand, foot and mouth disease is usually made on the basis of which of the
following?
a. Cultures.
b. Characteristic clinical signs.
c. Electron microscopy.
d. Serological testing.
31. Herpangina is caused by which of the following?

a. Human herpes virus 8 (HHV-8).
b. Human herpes virus 7 (HHV-7).
c. EBV.
d. Coxsackie virus subspecies.
32. Treatment of herpangina consists of bed rest and the use of which of the following?
a. Antifungal agents.
b. Antimicrobial rinses.
c. Antibiotics.
d. Antiviral agents.
33. How many serological types of human papilloma virus have been described?
a. 10.
b. 80.
c. 50.
d. 200.
Feedback
1. ANS: d
a. It has been estimated that 90% of adults harbour viruses that have been acquired as a
result of infection during earlier life.
b. It has been estimated that 90% of adults harbour viruses that have been acquired as a
c. It has been estimated that 90% of adults harbour viruses that have been acquired as a
d. Correct. It has been estimated that 90% of adults harbour viruses that have been acquired
as a result of infection during earlier life.

2. ANS: b
a. Virus assembly is not the principal basis for the development of the antiviral drugs that
are presently available.
b. Correct. Knowledge of the different steps in viral replication has been the principal basis
for the development of the antiviral drugs that are presently available.
c. Protein synthesis is not the principal basis for the development of the antiviral drugs that
are presently available.
d. Adsorption is not the principal basis for the development of the antiviral drugs that are
presently available.
REF: Antiviral agents, p. 180
3. ANS: b
a. Viral replication has not necessarily contributed to the difficulty in designing effective
antiviral drugs.
b. Correct. The intracellular nature of infection and the ability of viruses to establish latent
forms have contributed to the difficulty in designing effective antiviral drugs.
c. Protein synthesis has not necessarily contributed to the difficulty in designing effective
antiviral drugs.
d. The viral cell membrane has not necessarily contributed to the difficulty in designing
effective antiviral drugs.
4. ANS: b
a. The approximate size of viruses is 100–300 nm.
b. Correct. The approximate size of viruses is 100–300 nm.
c. The approximate size of viruses is 100–300 nm.
d. The approximate size of viruses is 100–300 nm.
5. ANS: c
a. The electron microscopy method has low specificity.
b. The electron microscopy method has low specificity.
c. Correct. Electron microscopy can be used to provide a provisional identification based
on the morphological appearance of viral particles but this approach has low specificity
and requires additional tests.
d. The electron microscopy method has low specificity.
6. ANS: c
a. Atazanavir was not the first true specific antiviral agent developed.
b. Lopinavar was not the first true specific antiviral agent developed.
c. Correct. The development of aciclovir was a milestone in antiviral therapy, representing
the development of the first true, specific antiviral agent.
d. Nexavir was not the first true specific antiviral agent developed.

7. ANS: d
a. Aciclovir is not most affective against Epstein–Barr virus.
b. Aciclovir is not most affective against cytomegalovirus.
c. Aciclovir is not most affective against Kaposi’s sarcoma herpes virus.
d. Correct. Aciclovir is a nucleoside analogue drug that has activity against members of the
herpes group of viruses, in particular HSV-1.
REF: Antiviral agents, pp. 180–181
8. ANS: c
a. Virus assembly is not the primary mechanism of action for aciclovir.
b. Inhibition of viral DNA synthesis is not the primary mechanism of action for
aciclovir.
c. Correct. Aciclovir acts by blocking viral replication.
d. Destruction of the viral cell membrane is not the primary mechanism of action for
aciclovir.
9. ANS: b
a. The name herpes comes from the Greek word ‘herpein’ which does not mean ‘slow’.
b. Correct. The name herpes comes from the Greek word ‘herpein’ which means to creep
(chronic, recurrent).
c. The name herpes comes from the Greek word ‘herpein’ which does not mean
‘prolong’.
d. The name herpes comes from the Greek word ‘herpein’ which does not mean ‘rapid’.
REF: Herpes viruses, p. 182
10. ANS: b
a. Primary infection with HSV-1 occurs almost universally in the population in the Western
world.
b. Correct. Primary infection with HSV-1 usually occurs during the first few years of life
and serum markers of infection with the virus are found almost universally in the popula-
tion in the Western world by 15 years of age.
c. Primary infection with HSV-1 occurs almost universally in the population in the Western
world.
d. Primary infection with HSV-1 occurs almost universally in the population in the Western
world.
REF: Herpes viruses, p. 182
11. ANS: d
a. HSV-1 is the acronym for Herpes simplex virus 1.
b. HCMV is the acronym for cytomegalovirus.
c. EBV is the acronym for Epstein–Barr virus.
d. Correct. The acronym for Kaposi’s sarcoma herpes virus is HHV-8 (human herpes
virus 8).
REF: Herpes simplex type 1 (HSV-1)–primary infection, Table 10.2, pp. 182–183
12. ANS: b
a. The agent of choice is aciclovir, not amoxicillin, for patients who present with signs and
symptoms of primary herpetic gingivitis.
b. Correct. The agent of choice is aciclovir for patients who present with signs and symp-
toms of primary herpetic gingivitis.
c. Chlorhexidine is not the agent of choice for patients who present with signs and symp-
toms of primary herpetic gingivitis.
d. The agent of choice is aciclovir, not polymixin, for patients who present with signs and
symptoms of primary herpetic gingivitis.
REF: Herpes simplex type 1 (HSV-1)–primary infection, pp. 182–183
13. ANS: c
a. Prodromal is symptomatic of the onset or early stage of a disease and is not the form in
which the HSV-1 remains in the tissues.
b. The HSV-1 that remains in the tissues is not in a resistant state.
c. Correct. Regardless of the use of an antiviral agent, HSV-1 is not eliminated from the
body following resolution of the acute symptoms and the virus remains within the tissues
in a latent form and can reactivate.
d. The HSV-1 that remains in the tissues is not in an active state.
REF: Herpes simplex type 1 (HSV-1)–primary infection, pp. 182–183
14. ANS: c
a. Up to 40% of HSV-1 positive individuals suffer from recurrent episodes of secondary
infection.
b. Up to 40% of HSV-1 positive individuals suffer from recurrent episodes of secondary
infection.
c. Correct. Up to 40% of HSV-1 positive individuals suffer from recurrent episodes of
secondary infection.
d. Up to 40% of HSV-1 positive individuals suffer from recurrent episodes of secondary
infection.
REF: Herpes simplex type 1 (HSV-1)–secondary infection, pp. 183–184
15. ANS: b
a. Lip sore is not the more commonly known term for herpes labialis.
b. Correct. Reactivation of HSV-1 characteristically produces herpes labialis, known more
commonly as a cold sore or fever blister.
c. Mucosal lesion is not the more commonly known term for herpes labialis.
d. Oral blister is not the more commonly known term for herpes labialis.
REF: Herpes simplex type 1 (HSV-1)–secondary infection, pp. 183–184

16. ANS: b
a. Hypoglossal nerve innervates the muscles of the tongue.
b. Correct. Traditionally, it has been thought that reactivated HSV-1 migrates from the
trigeminal ganglion to the peripheral tissues of the lips or face.
c. The zygomatic nerve supplies the skin of the cheek and temporal region, not the oral
cavity.
d. Buccal nerve provides sensory innervation to the skin and mucosa of the cheek.
REF: Herpes simplex type 1 (HSV-1)–secondary infection, p. 184
17. ANS: d
a. Herpes labialis does not characteristically begin on the buccal mucosa.
b. Herpes labialis does not characteristically begin at the gingival margin.
c. Herpes labialis does not characteristically begin at the attached gingiva.
d. Correct. Herpes labialis characteristically begins at the vermillion border of the lips.
18. ANS: b
a. Approximately 25% of episodes have no prodromal stage and the lesion initiates as
vesicles.
b. Correct. Approximately 25% of episodes have no prodromal stage and the lesion initiates
as vesicles.
c. Approximately 25% of episodes have no prodromal stage and the lesion initiates as vesicles.
d. Approximately 25% of episodes have no prodromal stage and the lesion initiates as vesicles.
19. ANS: c
a. Vesicles that rupture and crust over, not gingivostomatitis, is characteristic of herpes
labialis.
b. Vesiculobullous lesions are not characteristic of herpes labialis.
c. Correct. Within 48 hours the vesicles rupture to leave an erosion, which subsequently
crusts over and eventually heals, within 7–10 days.
d. Pyrexia is not characteristic of herpes labialis.
20. ANS: d
a. Poor nutrition does not necessarily predispose an individual to the development of herpes
labialis.
b. Toothbrush abrasion does not predispose an individual to the development of herpes
labialis.
c. Pre-existing gingivitis does not necessarily predispose an individual to the development
of herpes labialis.
d. Correct. Factors that predispose a susceptible individual to the development of herpes
labialis include sunlight, trauma, stress, fever, menstruation, and immunosuppression.

21. ANS: d
a. An antimicrobial rinse would not be effective to use prophylactically to prevent individu-
als with severe or frequent recurrences from experiencing additional outbreaks.
b. A stannous fluoride rinse would not be effective to use prophylactically to prevent indi-
viduals with severe or frequent recurrences from experiencing additional outbreaks.
c. Ganciclovir and foscarnet are two other antiviral agents that are used in specialist units
for treatment of infections due to cytomegalovirus.
d. Correct. Individuals with severe or frequent recurrences can benefit from the prophylactic
use of systemic aciclovir.
22. ANS: c
a. Latent HSV-1 is asymptomatic and sheds periodically in the saliva of up to 70% of the
population at least once a month.
b. Latent HSV-1 is asymptomatic and sheds periodically in the saliva of up to 70% of the
c. Correct. Latent HSV-1 is asymptomatic and sheds periodically in the saliva of up to
70% of the population at least once a month.
d. Latent HSV-1 is asymptomatic and sheds periodically in the saliva of up to 70% of the
23. ANS: b
a. Whooping cough is not caused by the varicella zoster virus (VZV).
b. Correct. VZV primary infection occurs most frequently in childhood, causing
chickenpox.
c. Respiratory infection is not caused by the VZV.
d. Pinkeye is not caused by the VZV.
REF: Varicella zoster virus (VZV) –primary infection, p. 185
24. ANS: a
a. Correct. Reactivation of latent VZV in sensory nerve ganglia produces the clinical condi-
tion of herpes zoster, which is more commonly described as shingles.
b. Cold sores are caused by HSV-1, not VZV.
c. Hand, foot and mouth disease is caused by Coxsackie viruses.
d. Glandular fever is caused by EBV.
REF: Varicella zoster virus (VZV)–secondary infection, p. 185
25. ANS: b
a. Oropharyngeal candidiasis is not associated with the EBV.
b. Correct. EBV has been associated with a number of infections that affect the orofacial
region including infectious mononucleosis.
c. Parotitis is not associated with the EBV.
d. Sialadenitis is not associated with the EBV.
REF: Epstein–Barr virus, p. 186

26. ANS: c
a. Acute upper respiratory infection does not present with fine, petechial haemorrhages in
the hard and soft palate.
b. Meningitis does not present with fine, petechial haemorrhages in the hard and soft palate.
c. Correct. The onset of a painful throat and submandibular lymphadenopathy accompa-
nied by fine petechial haemorrhages in the hard and soft palate is associated with the
onset of infectious mononucleosis.
d. Cytomegalovirus infection does not present with fine petechial haemorrhages in the hard
and soft palate.
REF: Infectious mononucleosis, p. 186
27. ANS: b
a. Aphthous ulcers do not present as corrugated white lesions on the lateral border of the
tongue, but as discrete round lesions with a yellow centre typically on oral mucosa.
b. Correct. Characteristically, hairy leukoplakia presents as a corrugated white lesion on the
lateral border of the tongue, although it has also been described on the dorsum of the
tongue and the buccal mucosa.
c. Median rhomboid glossitis is seen as a symmetrical shaped area in the midline of the
dorsum of the tongue.
d. Lichen planus does not present as a corrugated white lesion on the lateral border of the
tongue, although it has also been described on the dorsum of the tongue and the buccal
mucosa.
REF: Hairy leukoplakia, p. 186
28. ANS: b
a. Hodgkins lymphoma is not a tumour of the jaw.
b. Correct. Burkitt’s lymphoma is an aggressive tumour of the jaws seen in areas where
malaria is prevalent, especially in China and Southeast Asia.
c. Basal cell carcinoma is not a tumour of the jaw.
d. Non-Hodgkins lymphoma is not a tumour of the jaw.
REF: Burkitt’s lymphoma and nasopharyngeal carcinoma, p. 187
29. ANS: b
a. HHV-8 is not the aetiological agent of human papillomavirus.
b. Correct. HHV-8 has been encountered in all forms of Kaposi’s sarcoma and is believed
to be the aetiological agent of this condition.
c. HHV-8 is not the aetiological agent of human immunodeficiency virus.
d. HHV-8 is not the aetiological agent of SARS.
REF: Human herpes virus 8 (HHV-8), p. 187

30. ANS: b
a. The diagnosis of hand, foot and mouth disease is not made by culture.
b. Correct. The diagnosis of hand, foot and mouth disease is usually made on the basis of
the characteristic clinical signs. Lesions involve macular and vesicular eruptions on the
hands, feet and mucosa of the pharynx, soft palate, buccal sulcus or tongue.
c. Hand, foot and mouth disease is not diagnosed through electron microscopy.
d. Hand, foot and mouth disease is not diagnosed through serological testing.
REF: Hand, foot and mouth disease, p. 187
31. ANS: d
a. HHV-8 is not the cause of herpangina.
b. HHV-7 is not the cause of herpangina.
c. EBV is not the cause of herpangina.
d. Correct. Herpangina is a condition that occurs predominantly in children, and presents
as sudden onset of fever and sore throat with subsequent development of papular, vesicular
lesions on the oral mucosa and pharyngeal mucosa and is caused by a Coxsackie virus
subspecies.
REF: Herpangina, p. 187
32. ANS: b
a. Antifungal agents are not the treatment of choice for herpangina.
b. Correct. Treatment consists of bed rest and the use of an antimicrobial rinse such as
chlorhexidine.
c. Antibiotics are not the treatment of choice for herpangina.
d. An antiviral agent is not the treatment of choice for herpangina.
REF: Herpangina, p. 187
33. ANS: b
a. More than 80 serological types of human papilloma virus have been described.
b. Correct. More than 80 serological types of human papilloma virus have been described.
c. More than 80 serological types of human papilloma virus have been described.
d. More than 80 serological types of human papilloma virus have been described.
REF: Human papilloma virus, p. 188

C H A P T E R 11
Oral Implications of Infection in

Compromised Patients
Multiple Choice
1. Molecular techniques have identified which of the following microorganisms from cases of
osteoradionecrosis?
a. Staphylococci, including methicillin resistant Staphylococcus aureus (MRSA).
b. Oral Gram negative anaerobes, including Porphyromonas and Prevotella spp.
c. Streptococci, including S. intermedius.
d. Actinomyces, including A. israelii.
2. The number of immunocompromised individuals is increasing rapidly, mostly because of the

acquired immunodeficiency syndrome (AIDS) pandemic, but also because of which of the
following?
a. Premature births.
b. Alcohol syndrome.
c. Ageing population.
d. Intervention therapy (drugs which deliberately modify the immune system).
3. Which of the following microorganisms are associated with post-irradiation mucositis?

a. Candida albicans.
b. Non-oral Gram negative facultative bacteria.
c. Oral Gram negative anaerobes.
d. Staphylococci.
4. In patients suffering from loss of oral musculature due to Parkinson’s disease or following a
stroke, what of the following changes has been observed in the oral microflora?
a. An increase in the prevalence of yeasts.
b. An increase in the prevalence of enterobacteria and Acinetobacter.
c. An increase in the prevalence of staphylococci, including MRSA.
d. An increase in the prevalence of mycoplasmas.
5. Which of the following tests assesses the extent of susceptibility to infection of an immu-
nocompromised patient?
a. Proportion of white blood cells.
b. High-density lipoprotein (HDL).
c. Liver biopsy.
d. Alanine aminotransferase (ALT).
155
156 11—Oral Implications of Infection in Compromised Patients
6. Which of the following can cause an orofacial infection in a medically compromised patient?
a. AIDS.
b. Endocrine disorder.
c. Cardiac disorder.
d. Arthritic disorder.
7. Of the following, which orofacial infection might a patient with a neurological disorder
experience?
a. Mucositis following radiotherapy.
c. Gingival hyperplasia.
d. Oral fungal infection.
8. An opportunistic orofacial infection may be indicative of which of the following?

a. An underlying bacterial overgrowth.
b. A smoking habit.
c. Initial feature of systemic disease.
d. A hormonal disorder.
9. Radiation affects bone in which of the following ways?

a. Hypercellularity.
b. Increases risk for fracture (osteoporodic).
c. Hypervascularity.
d. Tissue hypoxia.
10. Cancer in the oral region is treated usually by which of the following?
a. Surgery.
b. Radiotherapy.
c. Chemotherapy.
d. A combination of all three.
11. Necrotising fasciitis of the cervical region of the neck is associated with which of the fol-
lowing microorganisms?
a. Flesh-eating streptococci (e.g., Streptococcus pyogenes).
b. Spirochaetes and fusobacteria (fuso-spirochaetal complex).
c. Anginosus group of streptococci and obligate anaerobes.
d. Non-oral Gram negative bacilli, e.g., Acinetobacter and Klebsiella spp.
12. A simple operation on irradiated tissues, such as a tooth extraction, can result in which of
the following?
a. Scar tissue formation.
b. Spontaneous death of the surrounding bone (necrosis).
c. Very sensitive tissue.
d. Contact dermatitis.
13. Death of the bone following irradiation can be progressive and is called which of the following?
a. Avascular necrosis.
b. Osteonecrosis.
c. Osteoradionecrosis.
d. Osteoporosis.
11—Oral Implications of Infection in Compromised Patients 157
14. Osteoradionecrosis has been associated with oral ulceration caused by all of the following
except which of the following?
a. Ill-fitting dentures.
b. Scaling of the teeth.
c. Restoration of occlusal tooth surfaces.
d. Facial bone fractures.
15. Xerostomia is associated with which of the following changes to the oral microflora?
a. An increase in staphylococci.
b. An increase in enterobacteria.
c. And increase in mutans streptococci and lactobacilli.
d. A decrease in yeasts.
16. With careful collimation, shielding of surrounding tissues, and fractionation, the incidence
of osteoradionecrosis has been reduced to which of the following?
a. 2–5%.
b. 10–15%.
c. 15–20%.
d. 25–30%.
17. Osteoradionecrosis is likely to arise due to which of the following?

a. Surgery.
b. Radiation, trauma and infection.
c. Antimicrobial side-effects.
d. Inadequate oral hygiene post-radiation therapy.
18. Although osteoradionecrosis is difficult to treat, which of the following is used as a

treatment?
a. Saline rinses.
b. Sodium fluoride trays.
c. Hormone therapy.
d. Antibacterial agents.
19. The non-specific inflammation of the oral mucosa resulting from irradiation is called which
of the following?
a. Aphthous stomatitis.
b. Mucositis.
c. Gingivostomatitis.
d. Candidiasis.
20. Irradiation mucositis can be largely alleviated by selective decontamination of the oral
cavity prior to and during irradiation therapy by the topical application of which of the
following?
a. Metronidazole.
b. Chlorhexidine and antifungal agents.
c. A combination of polymixin and tobramycin, plus antifungal agents.
d. Amoxicillin.
21. Which of the following is the rationale for the use of bisphosphonates in the treatment of
osteoporosis?
a. Bone is destroyed due to cancer.
b. Bone becomes brittle due to radiological treatment.
c. Calcium is gradually lost from bone.
d. Bone is compromised due to long-term antibiotic therapy.
22. Which of the following conditions can be exacerbated by bisphosphonate use?

a. Incidence of mucositis.
b. Fungal overgrowth.
c. Failure of bone to heal after extractions/osteonecrosis.
d. Incidence of human papilloma virus (HPV).
23. The main viral coat protein used by human immunodeficiency virus (HIV) to attach to
CD4+ lymphocytes is which of the following?
a. gp 80.
b. gp 100.
c. gp 120.
d. gp 180.
24. Staphylococcus spp. are not always considered a normal member of the resident oral microflora,
but they can be isolated from the mouth in which of the following patient populations?
a. Paediatric.
b. Debilitated.
c. Juvenile.
d. Healthy.
25. The anti-HIV drug treatment is known by which of the following acronyms?
a. AR-HIV.
b. T-AIDS.
c. HEART.
d. HAART.
26. Bisphosphonates are pyrophosphate analogues that can prevent osteoporosis by inhibiting
a. Leukocytes.
b. Osteoclast activity.
c. Insulin production.
d. Pancreatic enzymes.
27. Pyostomatitis vegetans is associated with the presence of which of the following?
a. Hypertension.
b. Encephalopathy.
c. Crohn’s disease.
d. Diabetes.
28. Cancrum oris (noma, gangrenous stomatitis) is which of the following?

a. Severe form of gingivostomatitis.
b. Severe form of lichen planus.
c. Severe form of mucositis.
d. Severe form of necrotising periodontal disease.
29. Cancrum oris is characteristically seen in which of the following patient population?
a. Over age 50 with a history of infective endocarditis and periodontitis.
b. Less than 10 years old, malnourished and history of recent viral infection.
c. Middle aged, history of diabetes and hypertension.
d. Over age 75 with a history of immune dysfunction and diabetes.
30. Which of the following can occur following a stroke (and is also seen in conditions such as
Parkinson’s disease)?
a. Severe form of gingivostomatitis.
b. Loss of control of oral musculature.
c. Necrotising fasciitis.
d. Xerostomia.
31. A serious, life-threatening, rapidly progressive infection subsequent to an acute dentoalveolar

abscess seen in the cervical region of the neck of immunocompromised individuals is which
of the following?
a. Severe gingivostomatitis.
b. Necrotising fasciitis.
c. Severe oral thrush.
d. Severe oral lichen planus.
32. Which of the following literally means ‘dry mouth’?

a. Alveolar osteitis.
b. Xerostomia.
c. Lichen planus.
d. Aphthous stomatitis.
33. Xerostomia predisposes the development of which of the following?

a. Herpes simplex type 1 (HSV-1).
b. Mucositis.
c. Lichen planus.
d. Necrotising fasciitis.
34. Xerostomia has several causes including which of the following?

a. Coxsackie virus infection.
b. Antimicrobial rinses.
c. Pharmaceutical and over-the-counter (OTC) drugs.
d. Excess of vitamin D.
35. The use of an antirejection agent can cause which of the following fibrous gingival enlarge-
ments to occur?
a. Stomatitis.
b. Aphthous stomatitis.
c. Gingival hyperplasia.
d. Periodontitis.
36. The connection between a post-stroke patient’s inability to swallow properly and pneumonia
is which of the following?
a. Mucositis.
b. Aspirated oral microorganisms.
c. Aphthous ulcers.
d. Oral thrush.
37. Which of the following enzymes is used to convert double-stranded RNA to complementary
DNA in HIV?
a. DNA gyrase.
b. Ribonuclease.
c. Reverse transcriptase.
d. Deoxyribonuclease.
38. Transmissible spongiform encephalopathies (TSEs) are caused by which of the following
infectious agents?
a. Virion.
b. Prion.
c. Unculturable bacteria.
d. HBsAg.
39. The human immunodeficiency virus infects predominantly CD4+ lymphocytes but can also
infect which of the following?
a. Macrophages.
b. Neutrophils.
c. Monocytes.
d. Mast cells.
40. The agents responsible for TSEs are difficult to treat. Which of the following is not an
attribute associated with these agents?
a. Bind firmly to stainless steel.
b. Possess antibiotic resistance to multiple drugs.
c. Resistant to autoclaving.
d. Resistant to strong disinfectants.
41. What is the approximate rate of transmission of HIV if infected blood is transmitted to an
uninfected person?
a. <5%.
b. 10%.
c. 25%.
d. 50%.
42. AIDS results from a depletion of CD4+ lymphocytes also known as which of the
following?
a. B-cells.
b. T-helper cells.
c. Macrophages.
d. Killer T-cells.
43. Agents that cause TSEs are composed on which of the following?
a. ds DNA.
b. ds RNA.
c. ss RNA.
d. Protein.
44. Which of the following lesions is strongly associated with HIV?

a. Necrotising stomatitis.
b. Thrombocytopenic purpura.
c. Candidosis.
d. Hand, foot and mouth disease.
45. Which of the following lesions is only moderately associated with HIV?
a. Hairy leukoplakia.
b. Varicella zoster virus.
c. Non-Hodgkins lymphoma.
d. Kaposi’s sarcoma.
46. HIV can easily penetrate the blood–brain barrier resulting in mental deterioration that can
be misdiagnosed as which of the following?
a. Meningitis.
b. Depression.
c. Generalized anxiety.
d. Dementia.
47. In the early stages of infection, HIV releases a protein, p24, which can be detected sometimes
as early as within which of the following?
a. One week to one month.
b. One to two months.
c. Three months.
d. Six months.
48. Hepatitis B can be found in the blood of infected patients. The detection of which of the
following can be used to diagnose hepatitis B?
a. HBsAg.
b. PRP.
c. Genomic viral DNA.
d. Genomic viral RNA.
49. One of the most significant advances in the treatment of HIV is the use of which of the following?
a. Active antiretroviral therapy.
b. Azothymidine (AZT).
c. Antiviral therapy.
d. Antibacterial agents.
50. The current vaccine for tuberculosis (TB) is known as which of the following?
a. MDR-TB.
b. MMR.
c. BCG.
d. XDR-TB.
51. Syphilis can present with oral lesions. Which of the following is the causative bacterium?
a. Treponema denticola.
b. Treponema socranskii.
c. Treponema pallidum.
d. Treponema putidum.
Feedback
1. ANS: b
a. Staphylococci have not been detected.
b. Correct. Oral anaerobes have been detected.
c. Streptococci have not been detected.
d. Actinomyces spp. have not been detected.
REF: Osteoradionecrosis, p. 191
2. ANS: d
a. The number of immunocompromised individuals is increasing rapidly because of the
AIDS pandemic and intervention therapy, not premature births.
b. The number of immunocompromised individuals is increasing rapidly because of the
AIDS pandemic and intervention therapy, not alcohol syndrome.
c. The number of immunocompromised individuals is increasing rapidly because of the
AIDS pandemic and intervention therapy, not an ageing population.
d. Correct. The number of immunocompromised individuals is increasing rapidly, mostly
because of the AIDS pandemic, but also because of intervention therapy (drugs which
deliberately modify the immune system).
3. ANS: b
a. Yeasts are not associated with this form of mucositis.
b. Correct. Gram negative facultatively anaerobic bacteria such as pseudomonads and
Klebsiella species are associated with post-irradiation mucositis.
c. Oral Gram negative anaerobes are not associated with mucositis.
d. Staphylococci are associated with ‘staphylococcal mucositis’ but not post-irradiation
mucosistis.
REF: Post-irradiation mucositis, pp. 191–192
4. ANS: b
a. The microflora in these patient groups becomes predominantly Gram negative.
b. Correct. The microflora in these patient groups becomes predominantly Gram negative
with Enterobacter spp. and Acinetobacter spp. predominating.
c. The microflora in these patient groups becomes predominantly Gram negative.
d. The microflora in these patient groups becomes predominantly Gram negative.
REF: Stroke and Parkinson’s disease, p. 193

5. ANS: a
a. Correct. Measuring the proportion of white blood cells and their function or degree of
abnormality.
b. A HDL measurement would not be relevant to assessing the function of a patient’s
immune system.
c. A liver biopsy would not be relevant to assessing the function of a patient’s immune
system.
d. The ALT measurement would not be relevant to assessing the function of a patient’s
immune system.
6. ANS: b
a. AIDS would represent an immune-compromised rather than a medically compromised
patient.
b. Correct. Endocrine disorders are one type of disorder that may lead a medically com-
promised patient to have an orofacial infection.
c. Cardiac disorders would predispose a medically compromised patient to have an orofacial
infection.
d. Arthritic disorders would predispose a medically compromised patient to have an oro
facial infection.
REF: Introduction, Table 11.1, p. 191
7. ANS: c
a. Patients with neoplastic disease who undergo radiotherapy often develop oral mucositis.
b. Angular cheilitis is often associated with haematinic deficiencies such as anaemia.
c. Correct. Gingival hyperplasia is often associated with the neurological disorder of
epilepsy.
d. An oral fungal infection is associated with respiratory disorders such as asthma.
REF: Introduction, Table 11.1, p. 191
8. ANS: c
a. An orofacial infection is not likely to be the initial feature of an underlying bacterial
overgrowth.
b. There can be many oral manifestations of chronic smoking but they are not necessarily
the initial presenting feature of systemic disease.
c. Correct. The status of the teeth and oral soft tissues is often a reflection of systemic
health. Thus, opportunistic orofacial infection may be the presenting initial feature of
systemic disease.
d. An orofacial infection is not likely to be the initial sign of a hormonal disorder.
REF: Introduction, pp. 190–191

9. ANS: d
a. Radiation causes hypocellularity.
b. Increased risk for fracture because of osteoporodic tissue is not one of the three ways that
radiotherapy destroys surrounding tissue.
c. Radiation causes hypovascularity.
d. Correct. Radiotherapy destroys the rapidly dividing cancer cells, but it also destroys
surrounding bone. This bone is highly susceptible to secondary radiation as it absorbs a
great deal of energy. Radiation causes hypocellularity, hypocellularity and tissue hypoxia.
10. ANS: d
a. Cancer in the oral region is treated usually by surgery, radiotherapy, chemotherapy or a
combination of all three.
b. Cancer in the oral region is treated usually by surgery, radiotherapy, chemotherapy or a
c. Cancer in the oral region is treated usually by surgery, radiotherapy, chemotherapy or a
d. Correct. Cancer in the oral region is treated usually by surgery, radiotherapy, chemo-
therapy or a combination of all three.
11. ANS: c
a. S. pyogenes is associated with necotising fasciitis of sites other than cervical regions of the
neck; this is due to bacteria of dental origin.
b. Necrotising fasciitis of the cervical regions of the neck is due to bacteria of dental origin.
c. Correct. Necotising fasciitis of the cervical regions of the neck is due to bacteria of dental
origin including members of the anginosus group of streptococci often in association with
obligate oral anaerobes such as Prevotella spp.
d. Necrotising fasciitis of the cervical regions of the neck is due to bacteria of dental origin.
REF: Necrotising fasciitis, p. 193
12. ANS: b
a. Scar tissue can be the result of a surgical procedure but not just post-irradiation therapy.
b. Correct. A simple operation on tissues which have been irradiated, such as a tooth
extraction, can result in spontaneous death of the surrounding bone (necrosis).
c. Very sensitive tissue may occur post-surgically but not just post-irradiation therapy.
d. Contact dermatitis is not a common tissue reaction post-surgically on irradiated areas.

13. ANS: c
a. Avascular necrosis is the death of bone tissue due to a lack of blood supply.
b. Osteonecrosis means death of bone which can occur from loss of blood supply.
c. Correct. Death of the bone after irradiation can be progressive and is called
osteoradionecrosis.
d. Osteoporosis is a medical condition in which the bones become brittle and fragile from
loss of tissue, but not due to irradiation therapy.
14. ANS: c
a. Death of the bone after irradiation can be progressive and is called osteoradionecrosis
and has been associated with oral ulceration caused by ill-fitting dentures, scaling of the
teeth, facial bone fractures and root canal therapy.
b. Death of the bone after irradiation can be progressive and is called osteoradionecrosis
c. Correct. The restoration of occlusal tooth surfaces is not related in any way to death of
bone after radiation therapy.
d. Death of the bone after irradiation can be progressive and is called osteoradionecrosis
15. ANS: c
a. Xerostomia is associated with an increase in proportions of cariogenic bacteria.
b. Xerostomia is associated with an increase in proportions of cariogenic bacteria.
c. Correct. Xerostomia is associated with an increase in proportions of cariogenic
bacteria.
d. Xerostomia can be associated with an increase in yeasts in the mouth.
REF: Xerostomia, p. 194
16. ANS: a
a. Correct. With careful collimation, shielding of surrounding tissues, and fractionation,
the incidence of osteoradionecrosis has been reduced to 2–5%.
b. With careful collimation, shielding of surrounding tissues, and fractionation, the inci-
dence of osteoradionecrosis has been reduced to 2–5%.
c. With careful collimation, shielding of surrounding tissues, and fractionation, the inci-
d. With careful collimation, shielding of surrounding tissues, and fractionation, the inci-

17. ANS: b
a. Osteoradionecrosis does not result from surgery.
b. Correct. Osteoradionecrosis is likely to arise due to radiation, trauma and infection.
c. Osteoradionecrosis is not due to side-effects of antimicrobials.
d. Osteoradionecrosis is not due to inadequate oral hygiene post radiation therapy.
18. ANS: d
a. Saline rinses are not the treatment of choice for this condition.
b. Sodium fluoride trays are not the treatment of choice for this condition.
c. Hormone therapy is not necessarily the treatment of choice for this condition.
d. Correct. Osteoradionecrosis is a difficult condition to treat despite the provision of an
antibacterial agent such as metronidazole or clindamycin, combined with surgery.
19. ANS: b
a. Aphthous stomatitis is not a consequence of irradiation of the oral region.
b. Correct. Another of the consequences of irradiation of the oral region is non-specific
inflammation of the oral mucosa, often called post-irradiation mucositis.
c. Gingivostomatitis is not a term used to describe a non-specific inflammation of the oral
mucosa resulting from irradiation of the oral region.
d. Candidiasis is not a term used to describe a non-specific inflammation of the oral mucosa
resulting from irradiation of the oral region.
REF: Post-irradiation mucositis, p. 191
20. ANS: c
a. Metronidazole is not used to alleviate irradiation mucositis.
b. Chlorhexidine is not used to alleviate irradiation mucositis.
c. Correct. Irradiation mucositis can be largely alleviated by selective decontamination of
the oral cavity before and during irradiation therapy by the topical application of the
combination of polymixin and tobramycin, plus an antifungal to prevent overgrowth by
yeasts.
d. Amoxicillin is not used to alleviate irradiation mucositis.
REF: Post-irradiation mucositis, pp. 191–192
21. ANS: c
a. Osteoporosis is a condition in which calcium is gradually lost from bone.
b. Osteoporosis is not brittle bone due to radiation.
c. Correct. Bisphosphonates are drugs used in the treatment of osteoporosis, a condition
in which calcium is gradually lost from bone.
d. Osteoporosis is a side-effect caused by antibiotic therapy.
REF: Bisphosphonate-associated osteonecrosis, p. 192

22. ANS: c
a. The incidence of mucositis is not exacerbated by bisphosphonate use.
b. Fungal overgrowth can be exacerbated by bisphosphonate use.
c. Correct. Some patients who take bisphosphonates can suffer from a failure of bone to
heal especially after extractions (bisphosphonate-associated osteonecrosis).
d. The incidence of HVP-1 is not exacerbated by bisphosphonate use.
23. ANS: c
a. The main viral coat glycoprotein is gp 120.
b. The main viral coat glycoprotein is gp 120.
c. Correct. The main viral coat glycoprotein is gp 120.
d. The main viral coat glycoprotein is gp 120.
REF: Human immunodeficiency virus (HIV) and AIDS, Figure 11.5, pp. 195–196
24. ANS: b
a. Staphylococcus spp. are not frequently isolated from paediatric patients.
b. Correct. Recent surveys of data from oral samples processed in microbiology laboratories
have shown that Staphylococcus spp. are frequently isolated from the mouth particularly
from debilitated or terminally ill patients.
c. Staphylococcus spp. are not frequently isolated from juvenile patients.
d. Staphylococcus spp. are not frequently isolated from healthy patients.
REF: Staphylococcal mucositis, p. 192
25. ANS: d
a. The anti-HIV drug treatment is highly active antiretroviral therapy (HAART).
b. The anti-HIV drug treatment is highly active antiretroviral therapy (HAART).
c. The anti-HIV drug treatment is highly active antiretroviral therapy (HAART).
d. Correct. The anti-HIV drug treatment is highly active antiretroviral therapy (HAART).
REF: Human immunodeficiency virus (HIV) and AIDS, pp. 194–197
26. ANS: b
a. Bisphosphonate use does not inhibit leucocyte activity.
b. Correct. The bisphosphonates are pyrophosphate analogues that can prevent osteoporo-
sis by inhibiting osteoclast activity.
c. Bisphosphonate use does not reduce the production of insulin.
d. Bisphosphonate use does not affect pancreatic enzymes.

27. ANS: c
a. Hypertension is not associated with pyostomatitis vegetans.
b. Encephalopathy is not associated with pyostomatitis vegetans.
c. Correct. Pyostomatitis vegetans is associated with the presence of active inflammatory
bowel disease, in particular, ulcerative colitis or Crohn’s disease.
d. Diabetes is not associated with pyostomatitis vegetans.
REF: Pyostomatitis vegetans, p. 193
28. ANS: d
a. Cancrum oris (noma, gangrenous stomatitis) is not a form of severe gingivostomatitis.
b. Cancrum oris (noma, gangrenous stomatitis) is not a form of severe lichen planus.
c. Cancrum oris (noma, gangrenous stomatitis) is not a form of severe mucositis.
d. Correct. Cancrum oris (noma, gangrenous stomatitis) is a severe form of necrotising
periodontal disease.
REF: Cancrum oris (noma, gangrenous stomatitis), p. 193
29. ANS: b
a. Cancrum oris (noma, gangrenous stomatitis) is characteristically seen in a patient less
than 10 years of age, malnourished and with a recent history of viral infection.
b. Correct. Cancrum oris (noma, gangrenous stomatitis) is characteristically seen in a patient
less than 10 years of age, malnourished and with a recent history of viral infection.
c. Cancrum oris (noma, gangrenous stomatitis) is characteristically seen in a patient less
d. Cancrum oris (noma, gangrenous stomatitis) is characteristically seen in a patient less
REF: Cancrum oris (noma, gangrenous stomatitis), p. 193
30. ANS: b
a. The occurrence of severe gingivostomatitis is not linked to stroke nor to Parkinson’s
disease.
b. Correct. Loss of control of oral musculature can occur following a stroke and is seen in
conditions such as Parkinson’s disease.
c. Necrotising fasciitis is not a condition that occurs subsequent to a stroke or in conditions
such as Parkinson’s disease.
d. Xerostomia is not a condition that occurs subsequent to a stroke or in conditions such
as Parkinson’s disease.
31. ANS: b
a. Severe gingivostomatitis is not a condition that leads to death.
b. Correct. Necrotising fasciitis is a serious, rapidly progressive infection that can result in
death, particularly in immunocompromised individuals.
c. Severe oral thrush is not a condition that leads to death.
d. Severe oral lichen planus is not a condition that leads to death.
REF: Necrotising fasciitis, p. 193

32. ANS: b
a. Alveolar osteitis is inflammation of the alveolar bone.
b. Correct. Xerostomia literally means dry mouth and can be caused by a variety of condi-
tions or treatments.
c. Lichen planus is a disease of the skin and/or mucous membranes.
d. Aphthous stomatitis is an oral ulceration.
33. ANS: b
a. Xerostomia does not predispose to the development of HSV-1.
b. Correct. Xerostomia predisposes to the development of mucositis and opportunistic
Candida infections of the oral mucosa.
c. Xerostomia does not predispose to the development of lichen planus.
d. Xerostomia does not predispose to the development of necrotising fasciitis.
34. ANS: c
a. Xerostomia is not commonly caused by virus infection.
b. Xerostomia is not commonly caused by antimicrobial rinses.
c. Correct. Xerostomia is a condition that is quite commonly caused by many pharmaceuti-
cal and OTC drugs.
d. Xerostomia is not commonly caused by an excess of vitamin D.
35. ANS: c
a. Stomatitis is not the term for gingival overgrowth of fibrous tissue.
b. Aphthous stomatitis is not the term for gingival overgrowth of fibrous tissue.
c. Correct. Following organ transplantation, it is necessary to take immunosuppressive
agents. The consequences of an antirejection agent is gingival enlargement due to over-
growth of fibrous tissue (gingival hyperplasia).
d. Periodontitis is not the term for gingival overgrowth of fibrous tissue.
REF: Gingival hyperplasia and immunosuppressive agents, p. 194
36. ANS: b
a. Mucositis does not lead to pneumonia.
b. Correct. Loss of control of oral musculature can occur following a stroke followed by a
change in the oral microflora; often the patient cannot swallow properly and aspirates
the microflora, causing pneumonia.
c. Aphthous ulcers do not lead to pneumonia.
d. Oral thrush does not lead to pneumonia.

37. ANS: c
a. DNA gyrase is involved in super-coiling of double-stranded closed-circular DNA.
b. Ribonuclease degrades RNA.
c. Correct. Reverse transcriptase is the name of the enzyme that converts double-stranded
RNA to DNA in HIV.
d. Deoxyribonuclease degrades DNA.
REF: Human immunodeficiency virus (HIV) and AIDS, p. 194
38. ANS: b
a. Virions relate to viruses, which are not involved in TSEs.
b. Correct. Prions are the agents responsible for TSEs.
c. Unculturable bacteria do not cause TSEs.
d. HBsAg is the hepatitis B surface antigen.
REF: Transmissible spongiform encephalopathies, pp. 198–200
39. ANS: a
a. Correct. The virus infects predominantly CD4+ lymphocytes but can also infect
macrophages.
b. The virus does not infect neutrophils.
c. The virus does not infect monocytes.
d. The virus does not infect mast cells.
40. ANS: b
a. Prions are difficult to treat because they bind firmly to surgical instruments and are
resistant to heat and disinfectants.
b. Correct. Prions are difficult to treat because they bind firmly to surgical instruments and
are resistant to heat and disinfectants. They are not affected by antibiotics, nor do they
have conventional antibiotic resistant genes.
c. Prions are difficult to treat because they bind firmly to surgical instruments and are
d. Prions are difficult to treat because they bind firmly to surgical instruments and are
REF: Transmissible spongiform encephalopathies, p. 198–200
41. ANS: a
a. Correct. The transmission rate of the virus is around 4% if infected blood is transmitted
to an uninfected person.
b. The transmission rate of the virus is around 4% if infected blood is transmitted to an
uninfected person.
c. The transmission rate of the virus is around 4% if infected blood is transmitted to an
uninfected person.
d. The transmission rate of the virus is around 4% if infected blood is transmitted to an
uninfected person.

42. ANS: b
a. CD4+ lymphocytes are also known as T-helper cells.
b. Correct. CD4+ lymphocytes are also known as T-helper cells.
c. CD4+ lymphocytes are also known as T-helper cells.
d. Killer T-cells belong to the CD8+ subset of lymphocytes.
43. ANS: d
a. Prions cause TSEs and are composed of protein.
b. Prions cause TSEs and are composed of protein.
c. Prions cause TSEs and are composed of protein.
d. Correct. Prions cause TSEs and are composed of protein.
REF: Transmissible spongiform encephalopathies, p. 198–200
44. ANS: c
a. Necrotising stomatitis is not strongly associated with HIV.
b. Thrombocytopenic purpura is not strongly associated with HIV.
c. Correct. Candidosis is strongly associated with HIV.
d. Hand, foot and mouth disease is not strongly associated with HIV.
REF: Human immunodeficiency virus (HIV) and AIDS; Table 11.3, p. 196
45. ANS: b
a. Hairy leukoplakia is strongly associated with HIV.
b. Correct. Varicella zoster virus is moderately associated with HIV.
c. Non-Hodgkins lymphoma is strongly associated with HIV.
d. Kaposi’s sarcoma is strongly associated with HIV.
REF: Human immunodeficiency virus (HIV) and AIDS; Table 11.3, p. 196
46. ANS: d
a. Meningitis is not related to HIV’s ability to penetrate the blood-brain barrier.
b. Depression is not related to HIV’s ability to penetrate the blood-brain barrier.
c. Generalized anxiety is not related to HIV’s ability to penetrate the blood-brain barrier.
d. Correct. HIV can easily penetrate the blood–brain barrier resulting in mental deteriora-
tion that can be misdiagnosed as dementia.

47. ANS: a
a. Correct. In the early stages of infection, HIV releases a protein, present in its core, called
p24, which can be detected sometimes within one week of infection, but always within
one month.
b. In the early stages of infection, HIV releases a protein, present in its core, called p24, which
can be detected sometimes within one week of infection, but always within one month.
c. In the early stages of infection, HIV releases a protein, present in its core, called p24, which
can be detected sometimes within one week of infection, but always within one month.
d. In the early stages of infection, HIV releases a protein, present in its core, called p24,
which can be detected sometimes within one week of infection, but always within one
month.
48. ANS: a
a. Correct. Hepatitis B surface antigen (HBsAg) can be used to diagnose the virus.
b. Hepatitis B surface antigen (HBsAg) is used to diagnose the virus.
c. Hepatitis B surface antigen (HBsAg) is used to diagnose the virus.
d. Hepatitis B surface antigen (HBsAg) is used to diagnose the virus.
REF: Hepatitis B, p. 200
49. ANS: a
a. Correct. One of the most significant advances in the treatment of HIV is the use of
active antiretroviral therapy.
b. Within one month of the first use of AZT, HIV mutants were reported that were resist-
ant to the drug.
c. One of the most significant advances in the treatment of HIV is the use of active anti
retroviral therapy.
d. Antibacterial agents are not an effective treatment of HIV.
50. ANS: c
a. MDR-TB refers to TB caused by a multi-drug resistant strain.
b. MMR is mumps, measles and rubella vaccine.
c. Correct. BCG (Bacillus Calmette-Guerin) is the current TB vaccine.
d. XDR-TB refers to TB caused by an extensively resistant strain.
REF: Tuberculosis, p. 201
51. ANS: c
a. T. denticola is an oral spirochaete.
b. T. socranskii is an oral spirochaete.
c. Correct. T. pallidum is the causative agent of syphilis.
d. T. putidum is an oral spirochaete.
REF, Syphilis, p. 202, and see also pp. 39–40

C H A P T E R 12
Infection Control
Multiple Choice
1. Which of the following defines the processes and precautions that can be taken to control
the spread of infection?
a. Chemical disinfectant.
b. Aseptic technique.
c. Infection control.
d. Surgery cleanliness.
2. The classification of infection control depends on the procedure being performed and risk
of which of the following?
a. Contamination.
b. Disinfection.
c. Transmission.
d. Splatter.
3. Treating all patients with the same precautions is the definition of which of the following?
a. Routine precautions.
b. Standard or universal precautions.
c. Patient specific precautions.
d. Procedure specific precautions.
4. HIV infection can be transmitted in dentistry by which of the following?

a. Inhalation of infected droplets.
b. Contact with contaminated dental unit water supplies.
c. Contact with skin.
d. Use of infected instruments.
5. Herpes simplex type 1 virus can be transmitted in dentistry by which of the following?
a. Sharps injury.
b. Contact with skin.
c. Inhalation of infected droplets.
d. Contact of infected material with skin or eyes.
6. Legionella spp. can be transmitted in dentistry by which of the following?

a. Back suctioning.
b. Direct injection of blood.
c. Surface (skin) contact with contaminated dental unit water.
d. Inhalation of infected droplets.
173
174 12—Infection Control
7. Methicillin resistant Staphylococcus aureus (MRSA) has been shown to have been transmitted
in dentistry by which of the following?
a. Contact with contaminated dental unit water supplies (DUWS).
b. Infected instruments.
c. Inhalation of infected droplets.
d. Contact with skin.
8. Mycobacterium tuberculosis has been shown to have been transmitted in dentistry by which
of the following?
a. Inhalation of infected droplets.
b. Skin contact with contaminated DUWS.
c. Direct injection of blood.
d. Infected instruments.
9. Hepatitis B virus has been shown to have been transmitted in dentistry by which of the
following?
a. Direct injection of blood.
b. Contact with contaminated dental unit water supplies.
c. Sharps injury.
d. Inhalation of infected droplets.
10. Microorganisms persist in DUWS as biofilms. Which of the following is not a feature of
these biofilms?
a. Provide a haven for opportunistic pathogens.
b. Can slough off and infect patients.
c. Can display an increased sensitivity to disinfectants.
d. Can contain oral bacteria.
11. The most infectious agent, constantly present in the oral cavity of at least 30% of the popula-
tion, is which of the following?
a. Hepatitis B virus.
b. Coxsackie viruses.
c. MRSA.
d. Herpes simplex type 1.
12. The herpes simplex virus is responsible for blindness in dental personnel due to which of
the following?
a. Lack of a vaccine.
b. Not wearing adequate eye protection.
c. Not using vinyl gloves.
d. Sharps injury.
13. Important infection control elements of personal protection do not include which of the
following?
a. Immunisation.
b. Eye protection.
c. Wearing coverage over hair.
d. Avoidance of sharps injuries.
12—Infection Control 175
14. Which of the following is not a recommended vaccination for dental personnel?
a. Diphtheria.
b. Hepatitis B.
c. Pneumonia.
d. BCG.
15. Which of the following can be a factor in contact dermatitis for dental personnel?
a. Thorough hand washing.
b. Latex rubber gloves.
c. Non-thorough hand washing.
d. Contamination with fungal agents.
16. To prevent the hands from becoming vectors of infection in dental procedures, which pro-
tocol would not be advised?
a. Use of handcream after every session.
b. Use of alcohol and disinfectant handrubs if hands are not visibly contaminated following
patient treatment.
c. Limit the wearing of jewellery.
d. Thoroughly drying the hands.
17. What percentage of dental personnel in the USA have been estimated to have detectable
antibodies to latex proteins?
a. 10%.
b. 40%.
c. 65%.
d. 75%.
18. Immunological contact dermatitis requires which of the following treatments?

a. More thorough handwashing procedures.
b. Anti-inflammatory agents.
c. Steroid or other systemic therapy.
d. Antibiotics.
19. The term used to describe the material that is coughed up by patients, and which may infect
the eye, is known as which of the following?
a. Inhalation debris.
b. Saliva debris.
c. Biofilm debris.
d. Splatter.
20. Which of the following regimes is not validated to sterilise a surgical instrument?
a. 134 ° C/3 min/2 bar pressure.
b. 121 ° C/15 min/1 bar pressure.
c. 115 ° C/30 min/1 bar pressure.
d. 100 ° C/45 min/1 bar pressure.
21. The best protection against aerosols is which of the following?

a. Mask.
b. High-vacuum suction.
c. Protective glasses.
d. Gloves.
22. Which of the following have a high potential for the transmission of serious infection?
a. Aerosols.
b. Contact with skin.
c. Sharps injuries.
d. Splatter.
23. Which of the following procedures produces the highest potential for a sharps injury?
a. Bending a needle.
b. Resheathing a needle.
c. Autoclaving broken glassware.
d. Putting contaminated glassware into disinfectant.
24. In order to reduce the risk of cross infection most surgeries incorporate three distinct areas
or zones. Which of the following is not one of these zones?
a. Operator’s zone.
b. Decontamination zone.
c. Assistant zone.
d. Patient zone.
25. Disinfection is the removal or killing of some microorganisms but not usually which of the
following?
a. Bacteria.
b. Fungi.
c. Spores.
d. Blood splatter.
26. Disinfection is reserved for four distinct places; these are (a) surfaces, (b) drains and spittoons,
(c) dental unit water supplies, and which of the following?
a. Impressions and appliances.
b. Light handles.
c. Hand piece.
d. Head of the x-ray tube.
27. Which of the following is the most important aspect of surface disinfection?
a. The use of an Environmental Protection Agency (EPA)-approved product.
b. Strength of the disinfectant used.
c. Making certain that the disinfectant is bactericidal.
d. How the product is used.
28. A combination of a bactericidal disinfectant and which of the following should be used on
drains and spittoons?
a. Alcohol.
b. Witch hazel.
c. Antibiotics.
d. Detergent.
29. Water delivered from DUWS is not sterile and can contain high numbers of opportunistic
pathogens. Which of the following has not been identified in outflowing water from DUWS?
a. Legionella pneumophila.
b. Mycobacterium spp.
c. MRSA.
d. Pseudomonas aeruginosa.
30. Which of the following is the final step in preparing a dental appliance and impression for
a laboratory procedure?
a. Rinse them off with a commercially available mouthrinse.
b. Brush each with a dentifrice.
c. Spray the surfaces with a disinfectant.
d. Immerse in a disinfectant.
31. The word decontamination is often misused; it is defined as the treatment of an instrument
to make it fit for re-use. Decontamination therefore involves both cleaning and which of the
following?
a. Immersion in disinfectant.
b. Sterilisation.
c. Drying.
d. Spraying with disinfectant.
32. The three methods currently used for instrument cleaning in dentistry are manual washing,
washer/disinfectors, and which of the following?
a. Ultraviolet (UV) light.
b. Deep immersion oil.
c. Ultrasonics.
d. Surface tension.
33. Which of the following is the least efficient method of cleaning instruments?
a. Washer/disinfectors.
b. Ultrasonic cleaning.
c. Manual cleaning.
d. UV light.
34. Which of the following is the most difficult to kill during the sterilisation process?
a. Pathogenic microorganisms.
b. Bacterial spores.
c. Prions.
d. Biofilms.
35. In dentistry, the most common process used for sterilisation is which of the following?
a. Manual cleaning.
b. Detergent bath.
c. Autoclave.
d. UV light.
Feedback
1. ANS: c
a. Chemical disinfection is part of an infection control protocol, not the definition of it.
b. Using an aseptic technique is part of an infection control protocol, not the definition of
it.
c. Correct. Infection control is defined as all the processes and precautions that can be
taken to control the spread of infection.
d. Surgery cleanliness is part of the platform of infection control, but does not define it.
REF: Infection control, p. 204
2. ANS: c
a. Contamination is the result of infection transmission.
b. Disinfection is an end goal of some infection control procedures, not a risk factor.
c. Correct. The classification of infection control depends upon the procedure being per-
formed and risk of transmission.
d. Spatter is a means of transmission of disease, but not the only one.
3. ANS: b
a. The correct term for treating all patients with the same precautions is Standard or
Universal Precautions.
b. Correct. Since most dental patients who asymptomatically carry disease are unaware of
their infectious status, it is wise to treat everyone with the same precautions; these are
often described as Standard or Universal Precautions.
c. Treating all patients with the same precautions is described as following Standard or
Universal Precautions.
d. Procedure-specific precautions do exist; however, when they are applied, they apply to all
patients, not just to some.
4. ANS: d
a. Cases of HIV infection transmitted in dentistry through the inhalation of infected drop-
lets have not been documented.
b. Cases of HIV infection transmitted in dentistry through contact with contaminated
dental unit water supplies have not been documented.
c. Cases of HIV infection transmitted in dentistry through contact with skin have not been
documented.
d. Correct. Cases of HIV infection transmitted in dentistry have been documented as being
caused by use of infected instruments.
REF: Which infectious diseases are transmitted by dentistry?, Table 12.1, p. 205
5. ANS: d
a. Herpes simplex type 1 virus has not been shown to have been transmitted in dentistry
through a sharps injury.
b. Herpes simplex type 1 virus has not been shown to have been transmitted in dentistry
by contact with skin.
c. Herpes simplex type 1 virus has not been shown to have been transmitted in dentistry
through inhalation of infected droplets.
d. Correct. Herpes simplex type 1 virus has been shown to have been transmitted in den-
tistry by contact of infected material with skin or eyes.
6. ANS: d
a. Legionella spp. have not been shown to have been transmitted in dentistry via back
suctioning.
b. Legionella spp. have not been shown to have been transmitted in dentistry via direct
injection of blood.
c. Legionella spp. have not been shown to have been transmitted in dentistry via skin contact
with contaminated dental unit water.
d. Correct. Legionella spp. have been shown to have been transmitted in dentistry by inhala-
tion of infected droplets from contaminated water in dental unit water systems.
7. ANS: d
a. MRSA has not been shown to have been transmitted in dentistry by contact with con-
taminated DUWS.
b. MRSA has not been shown to have been transmitted in dentistry by use of infected
instruments.
c. MRSA has not been shown to have been transmitted in dentistry by inhalation of
infected droplets.
d. Correct. MRSA has been shown to have been transmitted in dentistry by skin contact.
8. ANS: a
a. Correct. Mycobacterium tuberculosis has been shown to have been transmitted in dentistry
by inhalation of infected droplets.
b. Physical contact with contaminated DUWS has not been shown to transmit Mycobacterium
tuberculosis.
c. Direct injection of blood has not been shown to transmit Mycobacterium tuberculosis.
d. Use of infected instruments has not been shown to transmit Mycobacterium tuberculosis.
REF: Which infectious diseases are transmitted by dentistry?, p. 205

9. ANS: c
a. HIV, not Hepatitis B virus, has been shown to have been transmitted by direct injection
of blood.
b. Legionella spp. and Pseudomonas aeruginosa have been shown to have been transmitted by
contact with contaminated DUWS.
c. Correct. Hepatitis B virus has been shown to have been transmitted in dentistry by
sharps injury.
d. Tuberculosis, not hepatitis B virus, has been shown to have been transmitted by inhalation
of infected droplets.
10. ANS: c
a. Biofilms can be a haven from opportunistic pathogens, providing protection from
disinfectants.
b. Biofilms can slough off the wall of the tubing, and infect patients.
c. Correct. Biofilms display a decreased sensitivity to disinfectants.
d. Biofilms in DUWS can contain oral bacteria, derived by back-siphonage from previous
patients.
REF: Dental unit water systems, p. 209
11. ANS: d
a. Herpes simplex type 1, not hepatitis B virus, is the most infectious agent constantly
present in the oral cavity of at least 30% of the population.
b. Coxsackie virus is not the most infectious agent constantly present in the oral cavity of
at least 30% of the population.
c. MRSA is not the most infectious agent that is constantly present in the oral cavity of at
least 30% of the population.
d. Correct. The most infectious agent that is constantly present in the oral cavity in at least
30% of the population is Herpes simplex type 1.
12. ANS: b
a. Dental personnel who contract herpes simplex virus and experience blindness do not do
so because they did not get vaccinated.
b. Correct. The herpes simplex virus has been responsible for blindness, usually in dental
personnel who do not wear protective spectacles for eye protection.
c. In dental personnel who contract herpes simplex virus and experience blindness, it is not
related to not wearing protective gloves.
d. In dental personnel who contract herpes simplex virus and experience blindness, it is not
related to a sharps injury.

13. ANS: c
a. Immunisation is an important part of infection control measures.
b. Eye protection is an important part of infection control measures.
c. Correct. Wearing coverage over hair is not one of the important elements of personal
elements of infection control.
d. Avoidance of sharps injuries is an important part of infection control measures.
REF: Immunisation, p. 205
14. ANS: c
a. Diphtheria is a recommended vaccination for dental personnel.
b. Hepatitis B is a recommended vaccination for dental personnel.
c. Correct. Pneumonia is not a recommended vaccination for dental personnel.
d. BCG for tuberculosis is a recommended vaccination for dental personnel.
15. ANS: b
a. Thorough hand washing, while an important aspect of infection control, is not cause of
contact dermatitis.
b. Correct. Latex rubber gloves can cause contact dermatitis because they contain low
molecular weight proteins that can be immunologically active. These low molecular
weight proteins can penetrate the skin and induce inflammation; this condition is called
irritant contact dermatitis.
c. Non-thorough hand washing which is never appropriate is not the cause of contact
dermatitis.
d. Contamination with fungal agents is not cause of contact dermatitis.
REF: Immunisation, pp. 205–206.
16. ANS: c
a. Use of handcream after every session is advised to protect skin from drying.
b. Use of alcohol and disinfectant handrubs if hands are not visibly contaminated following
patient treatment is recommended.
c. Correct. All jewellery is to be eliminated, not merely limited.
d. Thorough drying of the hands protects them from further drying out when wearing
gloves.
REF: Hand protection, pp. 205–207
17. ANS: b
a. In the USA, it has been estimated that 40% of medical personnel have detectable anti-
bodies to latex proteins.
b. Correct. In the USA, it has been estimated that 40% of medical personnel have detect-
able antibodies to latex proteins.
c. In the USA, it has been estimated that 40% of medical personnel have detectable anti-
d. In the USA, it has been estimated that 40% of medical personnel have detectable anti-
REF: Gloves, p. 207

18. ANS: c
a. Hand washing is not an effective treatment for immunological contact dermatitis.
b. Anti-inflammatory agents are not an effective treatment for immunological contact
dermatitis.
c. Correct. Immunological contact dermatitis requires topical steroids as therapy.
d. Antibiotics are not an effective treatment for immunological contact dermatitis.
REF: Gloves, p. 207
19. ANS: d
a. The method of contamination through breathing is called inhalation. Spatter is the term
used for contaminated blood and saliva, coughed by a patient into the face of an
operator.
b. Spatter is the term used for contaminated blood and saliva, coughed by a patient into
the face of an operator.
c. Spatter is the term used for contaminated blood and saliva, coughed by a patient into
the face of an operator.
d. Correct. Spatter is the term used for contaminated blood and saliva, coughed by a patient
into the face of an operator.
REF: Eye and face protection, p. 208
20. ANS: d
a. 134°C/3 min/2 bar pressure is validated to sterilise a surgical instrument.
b. 121°C/15 min /1 bar pressure is validated to sterilise a surgical instrument.
c. 115°C/30 min/1 bar pressure is validated to sterilise a surgical instrument.
d. Correct. 100°C/45 min/1 bar pressure is not validated to sterilise a surgical
instrument.
REF: Sterilization of Instruments, Table 12.3, p. 211
21. ANS: b
a. A face masque is a means of protection from aerosols, but not the best means.
b. Correct. The best protection against aerosols is high-vacuum suction.
c. Protective glasses are not the best protection against aerosols.
d. Gloves are not the best protection against aerosols in high-vacuum suction.
REF: Eye and face protection, p. 208
22. ANS: c
a. Aerosols do not hold a high potential for the transmission of serious infection as they
do not involve blood to blood contact.
b. Contact with skin does not hold a high potential for the transmission of serious infection
as it does not involve blood to blood contact.
c. Correct. Sharps injuries hold a high potential for the transmission of serious infection
as they can involve blood to blood contact.
d. Splatter does not hold a high potential for the transmission of serious infection as it does
not involve blood to blood contact.
REF: Gloves, p. 208

23. ANS: b
a. According to infection control practices, needles should not be bent prior to disposal.
b. Correct. Inoculation injuries (often called sharps or needlestick injuries) have a high
potential for the transmission of serious infection as they can involve blood to blood
contact, and resheathing of needles is a potentially risky procedure.
c. Resheathing of needles is potentially the most risky procedure for sharps injuries.
d. Resheathing of needles is potentially the most risky procedure for sharps injuries.
REF: Inoculation injuries, p. 208
24. ANS: d
a. In order to reduce the risk of cross infection most surgeries incorporate three distinct
areas or zones: an operator’s zone, an assistant zone, and a decontamination zone.
b. In order to reduce the risk of cross infection most surgeries incorporate three distinct
c. In order to reduce the risk of cross infection most surgeries incorporate three distinct
d. Correct. In order to reduce the risk of cross infection most surgeries incorporate three
distinct areas or zones: an operator’s zone, an assistant zone, and a decontamination zone.
A ‘patient zone’ is not identified.
REF: Surgery design, p. 209
25. ANS: c
a. Disinfection normally kills most bacteria.
b. Disinfection normally kills most fungi.
c. Correct. Disinfection is the removal or killing of some microorganisms but not usually
spores.
d. Disinfection normally removes blood splatter.
REF: Surgery disinfection, p. 209
26. ANS: a
a. Correct. Disinfection is reserved for four distinct places; these are (a) surfaces, (b) drains
and spittoons, (c) dental unit water supplies, and (d) impressions and appliances.
b. Disinfection is reserved for four distinct places; these are (a) surfaces, (b) drains and
spittoons, (c) dental unit water supplies, and (d) impressions and appliances.
c. Disinfection is reserved for four distinct places; these are (a) surfaces, (b) drains and
d. Disinfection is reserved for four distinct places; these are (a) surfaces, (b) drains and
REF: Surgery disinfection, p. 209

27. ANS: d
a. Although a large number of types of surface disinfectant are available, how a product is
used is probably more important than their disinfectant classification.
b. Although a large number of types of surface disinfectant are available, how a product is
used is probably more important than the strength of dilution.
c. Although a large number of types of surface disinfectant are available, how a product is
used is probably more important than the mode of action.
d. Correct. Although a large number of types of surface disinfectant are available, it is how
they are used that is probably more important than their disinfectant action.
REF: Surface disinfection, p. 208
28. ANS: d
a. Alcohol should not be used for a disinfectant for drains and spittoons.
b. Witch hazel should not be used for a disinfectant for drains and spittoons.
c. Antibiotics should not be used for a disinfectant for drains and spittoons.
d. Correct. A combination of a bactericidal disinfectant and detergent should be used on
drains and spittoons.
REF: Drains and spittoons, p. 209
29. ANS: c
a. Water delivered from DUWS can contain L. pneumophila.
b. Water delivered from DUWS can contain mycobacteria.
c. Correct. MRSA have not been reported in water delivered from DUWS.
d. Water delivered from DUWS can contain P. aeruginosa.
REF: Dental unit water systems, p. 209
30. ANS: d
a. Rinsing off appliances and impressions with a commercially available mouthrinse is not
an effective way to disinfect appliances and impressions.
b. Brushing appliances and impressions with a dentifrice is not an effective way to disinfect
appliances and impressions.
c. Spraying the surfaces with a disinfectant is not an effective way to disinfect appliances
and impressions.
d. Correct. Before leaving the surgery, appliances and impressions should be washed to
remove debris and then immersed in a disinfectant.
REF: Disinfection of appliances and impressions, p. 210
31. ANS: b
a. Disinfecting does not provide the same safety as sterilisation.
b. Correct. The word decontamination is often misused; it is defined as the treatment of
an instrument to make it fit for re-use. Decontamination therefore involves both cleaning
and sterilisation.
c. Drying an instrument does not provide the same safety as sterilisation.
d. Spraying an instrument with disinfectant does not provide the same safety as sterilisation.
REF: Decontamination of instruments, p. 210

32. ANS: c
a. UV light is not one of the three methods used for instrument cleaning in dentistry.
b. Deep immersion oil is not one of the three methods used for instrument cleaning in
dentistry.
c. Correct. There are three methods currently used for instrument cleaning in dentistry;
they are manual washing, washer/disinfectors and ultrasonics.
d. Surface tension is not one of the three methods used for instrument cleaning in
dentistry.
REF: Critical and non-critical instruments, p. 211
33. ANS: c
a. Washer/disinfectors are an efficient method of cleaning instruments.
b. Ultrasonic cleaning is an efficient method of cleaning instruments.
c. Correct. Manual cleaning is the least efficient method of cleaning instruments, and
carries a risk of a sharps injury.
d. UV light is not a recommended method of cleaning instruments.
REF: Manual cleaning, p. 211
34. ANS: c
a. Pathogenic microorganisms are killed during sterilisation.
b. Spores are killed in the sterilisation process.
c. Correct. Prions are resistant to strong disinfectants, heat, autoclaving, and enzyme
activity.
d. Biofilms should be removed by efficient cleaning, and any residual bacteria are killed
during sterilisation.
REF: Transmissible spongiform encephalopathies, p. 199
35. ANS: c
a. Manual cleaning does not sterilise.
b. Detergent bath does not sterilise.
c. Correct. In dentistry, the most common process used for sterilisation is the autoclave.
d. UV light does not sterilise.
REF: Sterilisation of instruments, p. 211

INDEX
Index to question subjects. Readers are advised to B

also refer to the relevant answers. bacteraemia 121–122
bacterial cell communication 60
bacterial density 42–43
A bacterial overgrowth 5
abscess 102 bacteriocins 63
dentoalveolar 102–105, 159 BCG vaccine 161
periodontal 103 beta-lactamase producers 103
acetic acid 63 biofilm 2, 5–10, 20–26, 41, 59
aciclovir 82, 143–144, 146 antimicrobial tolerance 61–62
Actinomyces 61, 77, 101, 107 dental unit water systems 174
Actinomyces naeslundii 23 formation 60–62
actinomycosis, cervicofacial 101–102, 105, 107 properties 59, 62, 64
adhesin(s) 43–44, 60, 120 structure, study techniques 41
adhesin-receptor interactions 60 bisphosphonates 158
adhesion of microbes 43, 60–62, 83 blood agar 23, 41
aerobes 8 bone
aerosols, protection against 176 antimicrobial penetration 119, 121
ageing 39–40, 77 bisphosphonates and 158
Aggregatibacter actinomycetemcomitans 24, radiation damage and necrosis 156–157
80–81 buffering system 7
AIDS see HIV infection/AIDS Burkitt’s lymphoma 147
allogenic succession 39
American Type Culture Collection 21
amoxicillin 81, 102, 119, 121 C
amylase 7, 44 calcium loss 158
anaerobes 8, 41, 43, 45, 155–162 calculus 63
black-pigmented 23, 39 cancrum oris (noma) 82–83, 158–159
facultative 42, 62 Candida 26, 40, 42, 107, 130–134
obligate 39–40, 61, 78–79, colonisation by 130
102, 156 hydrolytic enzymes 131
angular cheilitis 107, 133 secondary lesions 133
antagonistic interactions 64 Candida albicans 25, 40, 130–131
antibiotic(s) 104, 118–122, 157 candidosis (oral) 130–131, 134, 161
broad spectrum 44, 132 acute erythematous 132
intravenous 121 chronic erythematous 134
resistance 10, 61, 102–103, 118–122 chronic hyperplastic 132–133
antifungal agents 134 chronic mucocutaneous 133
antimicrobial agent(s) 9–10, 59, 84–85, 120 predisposing factors 133–134, 140–142
biofilm cell tolerance to 61–62 Capnocytophaga gingivalis 22
maximum concentrations 120 capnophilic bacteria 22
penetration of bone 119, 121 carbohydrate(s) 24
prophylactic 118–129 fermentable 8–9, 21, 44, 76
selection 119 metabolism/fermentation 44, 76
antimicrobial peptides 134 carbon dioxide 22, 38, 61
antirejection agents 159 caries, dental 7, 22, 24, 75–100, 104
antiretroviral therapy 158, 161 enamel 24, 76–77
antiviral drugs 143–144 process 76
artificial sweeteners 82 root-surface 24, 76–77
aspiration of oral microbes 160 secondary 77
autoclaves 177 cariogenic potential 24
187
188 INDEX
CD4+ lymphocytes 158, 160 enolase 41, 59

cell–cell signalling 64 epidemiological surveys 76
cell mediated immunity 40, 133 Epstein–Barr virus (EBV) 146–147
cellulitis 102 erythromycin 103
cervicofacial actinomycosis 101–102, 105, 107 exopolymer 21
chemotaxonomy 20 eye protection 174
chewing gum 85
children 82–83, 107
chlorhexidine 10, 82, 84–85, 105 F
classification of microorganisms 20–21 facial lacerations 105
cleaning of instruments 177 fasting 44
cold sores (herpes labialis) 145–146 fermentation of carbohydrates 21
colonisation (microbial) 1, 5–6, 24, 37–58 fluorapatite 84
fungal 130 fluoride 76, 82, 84
resistance 44 foetus 37
colony counting 41 foreign material, in periodontal pocket 103
competition, bacterial 43, 63 fructan 21–22
confocal microscopy 41 fungal infections 130–142
contact dermatitis 175 fungal microflora 25
contamination of samples 102, 106 fungal spores 176
Coxsackie virus 147
cross-infection prevention 176
cryptitopes 60 G
culture, of microbes 21, 25, 40–41 gene transfer 64
culture medium 41 gingiva 6
cytokines 105 gingival crevice 6, 23, 39, 62, 77
gingival crevicular fluid (GCF) 7–8, 80–81
gingival hyperplasia 156, 159
D gingivitis 78–79
decontamination 157, 177 chronic marginal 78
defensins 9 herpetic 144
demineralisation 76 pregnancy 82
dental appliances, preparation 176–177 glossitis, median rhomboid 133
dental unit water systems (DUWS) 174, 177 glucan 22, 45
dentoalveolar abscess 102–105, 159 glycogen 44
dentoalveolar infection 103 glycosidase 8, 63
dentures 42, 134 Gram negative bacteria 25, 39, 80,
detergents 176 155–162
diabetes mellitus 82, 134 anaerobes 45, 79
disinfectants 174, 176 cocci 24–25
disinfection process 176 overgrowth 5
DNA extraction 21 Gram positive cocci 23
DNA-DNA hybridisation 42 Gram staining 41
drug addicts 122
dry socket 101
H
HAART see highly active antiretroviral treatment
E habitat 1–2, 5–19
ecological plaque hypothesis 75, 80 hairy leukoplakia 146
ecology, microbial 1–2, 5–19 halitosis see odour, mouth
electron microscopy 62, 143 hand, foot and mouth disease 147
enamel 5, 24, 60, 76 H+/ATPase 43
endocrine disorders 156 Helicobacter pylori 1
endodontic infections 103 hepatitis B/hepatitis B virus 161, 174
endotoxin 103 herpangina 147
INDEX 189
herpes labialis (cold sores) 145–146 latex, antibodies and dermatitis due to 175
herpes simplex type 1 (HSV-1) 26, 82, 174 lectin-mediated interaction 61
primary infection 144 Legionella, transmission 173
reactivation/recurrence 145–146 lipoteichoic acid (LTA) 120
transmission 173 lymphadenitis 104, 107
treatment 82, 144 lysozyme 6
herpes viruses 144
herpetic gingivitis 144
highly active antiretroviral treatment M
(HAART) 158, 161 malodour see odour, mouth
histatins 134 maxillo-facial infections 23
HIV (human immunodeficiency virus) 158, 161 metabolism (microbial) 7, 9, 37–58, 64, 76
HIV infection/AIDS 80, 131, 155, 160–161 methicillin resistant Staphylococcus aureus
transmission 173 (MRSA) 174, 177
homeostasis, microbial 39, 64 metronidazole 81
homeostatic hypothesis 75 microbial ecology 1–2, 5–19
host defence system 1, 5–6, 9, 83 microflora, resident 1, 20–36
evasion 39 composition 21
human herpes virus 8 (HHV-8) 144, 147 determining composition 40–41
human papilloma virus (HPV) 147 fungal 130–134
hyphae 131 loss of oral musculature and 155
microorganism number 2
minimum inhibitory concentration (MIC) 106
I
molecular analysis 21, 40, 42, 155–162
identification, of microbes 21, 41
mother, microbe transfer from 37–38, 77
IgA, secretory (sIgA) 5, 10
mouthrinse/mouthwash 10, 85
IgA1 protease 38
mucins 6, 8, 63
IgM (immunoglobulin M) 7
mucositis 159
immunocompromised patients 155–172
post-irradiation 155, 157
immunosuppression 151
mutans streptococci 22, 38, 44, 157
impressions, preparation 176–177
caries 77
infected joint replacements 120–121
Mycobacterium tuberculosis, transmission 174
infection control 173–185
Mycoplasma 26
infectious mononucleosis 146
infective endocarditis 118, 120–122
inflammation 8, 77, 79, 102, 104–105, 122
N
innate immunity 9
necrotising fasciitis 156, 159
intergeneric coadhesion 60
necrotising ulcerative gingivitis (NUG) 80–81
Neisseria species 24, 61
J neurological disorders 156
jewellery, wearing of 175 neutrophils 6, 8, 81, 83
joint replacements 120–121 newborn, microbial colonisation 37–38, 77
noma (cancrum oris) 82–83, 158–159
nutrients, microbial 6, 9
K
competition for 63
Kaposi’s sarcoma 147
saliva components as 7
Kaposi’s sarcoma herpes virus (HHV-8) 144, 147
supply for microflora/pathogens 44, 62, 101
Koch’s postulates 75–85
L O
lactate 64 odour, mouth 25, 39, 42, 45, 101
Lactobacillus 9, 24, 157 opportunistic pathogens 23, 107, 133, 156
enamel dental caries 77 oral cancer 132, 156
root-surface caries 77 oral disease, spread 2
latent infections 144 oral healthcare, disparities 2
190 INDEX
oral musculature, loss 155, 159 Prevotella species 25, 82, 155–162
orofacial bacterial infections 101–117 prions 160–161, 177
osteomyelitis, of jaw 104 propionic acids 63
osteoporosis 158 protozoa 20
osteoradionecrosis 156–157 Pseudomonas aeruginosa 1
oxidation-reduction potential 8, 38 puberty 39
oxygen 8, 20–26, 61 pulmonary infections 5, 78, 160
pulp death 104
pus, aspiration 101–102, 106
P pyostomatitis vegetans 158
palate 42 pyrexia 5
Parkinson’s disease 155, 159 pyrophosphate 63
parotid gland 106
parotitis, suppurative 106
passive inoculation 37–45 Q
pathogens 1 quorum sensing 60
pellicles 43, 59–60
penicillins 102–103
PEP-PTS (phosphoenolpyruvate-mediated R
phosphotransferase) 44 radiation damage 156
pericoronitis 105–106 remineralization 76
peri-implantitis 105 respiratory pathogens 1
periodontal abscess 103 reverse transcriptase 160
periodontal destruction, enzymes 83 root planing 81–82
periodontal disease 24, 75–100
general health and 84
periodontal pocket 40, 43, 77–78, 80, 103 S
temperature 8 saliva
periodontitis 79, 101–107 bacterial density 42
acute 78 buffering system 7
aggressive 78, 80–81 components 6–7, 10
chronic 78–79, 84 flow 40, 60, 130
personal protection 174 gingival crevicular fluid, comparison 7
pH 7, 9, 20–26, 43, 77–78 microbial colonisation control 6
phagocytosis 119 salivary glands 7, 106
phospholipases 131 salivary tests 83
pioneer species 38, 60 sampling technique for infections 101
plaque, dental 20–26, 59–74, 101–107 secondary feeder 64
animal 62 secreted aspartyl proteinases
diseases mediated by 75–100 (ASPs) 131
doubling time 61 sharps injury 174, 176
hypotheses 75, 80 shingles 146
maturation 22 sialadenitis 106
subgingival 25 Sjögren’s syndrome 106
vortexing, of sample 41 smoking 40, 132
plaque fluid 62 species 21
pneumonia 78, 160, 175 specific plaque hypothesis 75
polymicrobial infections 101, 103 spirochaetes, oral 24–25, 39
polyols 85 splatter 175
Porphyromonas 155–162 standard (universal) precautions 173
Porphyromonas endodontalis 25 staphylococci 105, 118, 122, 158
Porphyromonas gingivalis 9, 23, 80, 83 lymphadenitis 104
post-irradiation mucositis 155 sterilisation, of instruments 175,
post-operative infections 118–121 177
pregnancy 82 steroid inhalers 132, 134
INDEX 191
streptococci (Streptococcus) 1, 20, 22–23, transmissible spongiform encephalopathies

42, 61, 120 (TSEs) 160–161
adhesins 44 transmission, of infections 173–174, 176
facultative anaerobes 42 vertica 37–38, 77
mutans see mutans streptococci transport, microbial 60
pioneer community 38 trauma 104–105
Streptococcus intermedius 23 Treponema 24
Streptococcus mutans 22, 43, 63, 80 see also Treponema denticola 104
mutans streptococci Treponema pallidum 162
metabolism 45 Trichomonas tenax 20
Streptococcus pyogenes 23 triclosan 85
Streptococcus salivarius 21, 23, 37 trigeminal ganglion 145
Streptococcus sanguinis 120 tuberculosis 161
Streptococcus sobrinus 20, 76 twins, microflora 10
Streptococcus vestibularis 23
stroke 155, 159–160
subgingival calculus 63 U
subgingival environment 78 ultrasonic cleaning 177
subgingival plaque samples 6 urea 38
submandibular gland 106
succession, of microorganisms
38–39, 60, 62 V
sugars, fermentation 20, 63 vaccination 175
sugary drinks/food 7 valvular insufficiency 122
sulphate-reducing bacteria 25 Van der Waals forces 61
sulphur granules 105 varicella zoster virus (VZV) 146, 161
surgical drains 104 Veillonella 25, 63
surgical site infections 118–119 vertical transmission 37–38, 77
swallowing 9 vestibular mucosa 23
synergistic microbial interactions 63 viral infections (orofacial) 143–154
syphilis 162 virulence factors 81, 83, 131
viruses 26, 143 see also names of
specific viruses
T
temperature
oral cavity 8 W
periodontal pocket 8 white blood cells 155
tissue damage, by pathogens 83 wound infections, oral 119
tongue 42, 133
as microbial habitat 5, 26
white lesions on border 146 X
tooth eruption 39 xerostomia 64, 106, 157, 159
tooth surface 22
caries 76
lowest microbial community 7 Y
protection against microorganisms 6 yeasts, overgrowth by 10

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Revised and Updated Edition

This edition is for sale in the

Last digit is the print number: 9 8 7 6 5 4 3 2 1

7 Orofacial Bacterial Infections 101

2. Which of the following is true about resident microflora of a host?

9. What is the term used to describe the growth of microorganisms on a surface?

REF: Microbial ecology, pp. 4–5

REF: The human microflora, pp. 1–2

REF: The oral microflora in health and disease, pp. 2–3

REF: The oral microflora in general health, pp. 5–6

REF: The human microflora, p. 2

REF: The human microflora, Figure 1.1, p. 2

REF: The human microflora, Figure 1.1, pp. 1–2

REF: The scale of oral disease, p. 3

REF: Microbial ecology, pp. 4–5

REF: Oral microflora and general health, p. 5

The Mouth as a Microbial Habitat

6. Which of the following are not innate host defence peptides?

9. Mucins play a role in which of the following?

28. Oxidation-reduction level at a site is usually expressed as which of the following?

30. Lactobacillus species prefer to grow at which of the following conditions?

36. Porphyromonas gingivalis is an obligate anaerobe which prefers to grow at

37. Which is the predominant immunoglobulin in saliva?

REF: The mouth as a microbial habitat, p. 8

REF: Innate immunity, p. 18

REF: The mouth as a microbial habitat, p. 8

REF: The mouth as a microbial habitat, p. 9

REF: Innate immunity, p. 20

REF: Innate immunity, pp. 18–20

REF: GCF, pp. 12–14, Figure 2.6, p. 11

REF: Saliva, Table 2.2, p. 11

REF: Saliva, Table 2.2, p. 11

REF: Gingival crevicular fluid (GCF), p. 14

REF: Redox potential/anaerobiosis, p. 15

REF: Redox potential/anaerobiosis, p. 15

REF: Redox potential/anaerobiosis, pp. 14–15

REF: pH, Figure 2.4, p. 14

REF: Host defences, p. 17

REF: Host defences, p. 18

REF: Host defences, p. 19

REF: pH, Figure 2.4, pp. 14–16

REF: Saliva, pp. 11–12, and GCF, pp. 12–14

REF: Host genetics, p. 21

REF: Antimicrobial agents and inhibitors, p. 21

REF: Antimicrobial agents and inhibitors, pp. 21–22

The Resident Oral Microflora

2. Which of the following protozoa are found in the mouth?

3. Classification of microorganisms is the process of which of the following?

4. Early classification schemes relied heavily on which of the following?

9. Of the following, which is considered a disadvantage to using a culture approach to deter-

12. Which of the following classification represents a collection of strains?

21. Which of the following is a bacterium that is capnophilic?

31. An increased level of lactobacilli correlates to which of the following?

35. Oral spirochaetes fall within which genus?

37. Which of the following statement about oral spirochaetes is false?

39. The sulphate-reducing bacteria such as methanogens contribute to which of the

REF: The resident oral microflora (introduction), p. 24