PERIODONTOLOGY | MIDTERMS
DEA 16-17 | HARA, MARIKO D.
Etiology and Microbiology of Periodontal Diseases
Koch’s postulate
- Robert Koch – fa ther of Anthrax
- Compa red MO of i nfected to healthy a nimal
- MO a nd other pathogens must be present i n all cases of
di s ease
- Pa thogen must be isolated from dead host and grown in
pure cul ture
- Pa thogen from pure culture must ca use the disease when
i noculated into a healthy, s usceptible lab animal
- Pa thogen must be reisolated from the new host a nd
s hown to be the same as the originally i noculated
pa thogen
Epidemiology postulates
- Di rect relationship of quality of microorganism for
ca us ation of disease
- Exa mple: TB – tubercobacilli
Pres ence of s pecific microorganism
- Sa me kind of bacteria will be present i n the same disease
- Refers to heterogenous bacteria (never homogenous)
Periodontal disease
- Infl ammatory disease – host response
- Infl ammation is initiated by ba cteria
- Des truction of tooth treatment of periodontium clinical
s i gns of diseases
 The a ccumulation and metabolism of bacteria on ora l surfaces
is considered the primary cause of dental ca ries, stomatitis,
peri -implant i nfections, gingivitis and periodontitis in
susceptible individuals
*dependent on the host
Etiology
- Dental plaque – bi ofilm; primary ca use
- Ca l culus – ca lcified plaque; secondary ca use
*Materia alba – s oft deposit; food debris; ca n be ca lled plaque;
ca n be a ttached to a ny hard surface
*Gingival crevicular fluid – wi thi n the sulcus
*Commensals – endogenous bacteria; a lways within the saliva
Differentiating factors of saliva when in the sulcus
- More concentrated
- Di fference in temperature
- Di fference in pH
- Concentration of nutrients (organic)
*How much plaque do we have?
1mm 3 pl a que (1mg) > 100,000,000 ba cteria
 Dental plaque i s matrix enclosed bacterial population
a dherent to each other a nd / or to s urfaces or i nterface
- Uni que ecosystem
- Ba cterial species form a community
- Nutri ent s ource: gingival crevicular fluid
- Ba cteria communicate by means of signals
Quorum sensing
- Mecha nism of i ntercellular communication
- Si gnalling process
- Ba cteria ca n coordinate their a ctions
- Cel l -density dependent
- Medi ated by s mall diffusible molecules termed
a utoinducers
- Popul ation-dependent a daptive behaviour
Autoinducers
- Extra cel lular s ignalling molecules
- G + bacteria – vi a di ffusible peptides
- Coaggregation – s pecific cell to cell recognition occurs
between genetically distinct cell types
- Bridging – formed when a common partner s erve as a
bri dge or connection between 2 di fferent species
- Autoinducer 2 – uni versal signalling mediating messages
a mong the species
- Adsorption – a thi n continuous membrane or cuti cle
composed primarily of saliva ry components
- Passive transport – revers ible adhesion
- Coadhesion
- Multiplication
*Verti cal columnar a ccumulation
Formation of plaque
1. Ads orption
2. Pa s sive tra nsport
3. Coa dhesion of later colonizers to already a ttached earlier
col onizers
4. Mul ti plication
Microbial film
- Cooperating community of va rious types of
mi croorganisms
- Protecti ve matrix
- Di fferent environment
- Pri mi tive communication system
- Res istant to antibiotics, a ntimicrobial a nd host response
*If the px i s compromised, no need for AB

 Antibiotics – from l i ving things, specific: G +, G -
 Antimicrobial – from chemicals, broader s pectrum:
a nti fungal, a ntiviral, antibacterial
- Inherent property used superficially:
Substantivity – l ength of time that AM s ta ys within
the environment that its tryi ng to destruct
- The l onger a n AM s tays within environment,
effect of AM has to s tay on longer a nd latch on
l onger
- Its more challenging to have that substantivity
i n wet envi ronment
- Mouthwashes, toothpastes (paste – more
effective acc to s tudies; gel – more s olid, colloid
s us pension s o you would think i t lasts longer)
Biological effects
- Pl a que ca n a ct as a s ingle unit
*Why? Synergism inside contained biofilm
- Di fferent species cooperate within biofilm
- Forma tion is influenced by coaggregation, bridging a nd
a utoinducers
*Commensals within salivary fl ow >>> l ayer of that gets
a tta ched to tooth surface, whatever s pecies gets to be
encl osed within that cluster of biofilm = early colonizers
>>> s a livary fl ow continues that there will be l ate
col onizers (quorum sensing by early col onizers)
*From gra m + l inear a ccumulation of biofilm species, you
wi l l get more of gram -
*Innate i mmunity wi thin crevice – wha tever passes
through the crevice is being handled by your a natomic
ba rri er (junctional epithelium) vi a sloughing off o f
epi thelial cells. You have inflammatory cells in connective
ti s sue l ayer that just penetrate from CT to JE (fa st
os mosis). Alongside epithelial cells that get s loughed off,
you a l so have neutrophils a nd macrophages that i s why
you don’t get sick, no i nitiation of host response, there is
i mmunity of i nnate response
*Atta chment breached already – potent surface to reach
deeper; composition of biofilm: MO becomes mixed,
more concentrated to become gram -
- Exa mple: Fusobacterium nucleatum – forms “bridge”
between early and late colonizers
The problem with biofilms
*No a mount of water ca n tear out the biofilm, you need to scrub
- Ma rkedly enhanced resistance to chemical a ntimicrobial
a gents a nd a ntibiotics
*No ma tter how much mouthwash your px use, there is
s ti ll bad breath because of biofilm
- Structure ma y restrict the penetration of the
a nti microbial a gent
*Ma tri x becomes a l ittle bit more solid
PERIODONTOLOGY | MIDTERMS
DEA 16-17 | HARA, MARIKO D.
- Agent ma y a dsorb to surface organisms and not a ffect
thos e within the biofilm
*Wha tever the early colonizers, hindi maaabot yung
pi naka i lalim, s o balewala, s ayang lang ang pera
- Bi ofilm envi ronment may be unfavourable for optimal
a cti on of same drugs
*Not a l l i nfections naman kasi require
*Ameri can news: journalism a rticle “Flossing is a waste of ti me”
but i t i s a djunct to brushing (floss > mouthwash)
- Sti l l… AB have a clear benefit i n terms of a mean
peri odontal attachment level a gainst post-therapy
Specific bacteria in dental plaque
Periodontopathogens
- Should be associated with periodontitis (based on
modi fications of Koch’s postulate)
- Mus t be a bsent or present i n much s maller numbers in
peri odontically healthy s ubjects
- Hos t response should be elucidated
- Ani mal models for the determination of pathogenicity
s hould be demonstrated
- Uni que mechanism of pathogenicity s hould be indicated
- Cl i nical improvement after treatment must eliminate
pa thogen
Difficulties in identifying periodontal pathogens
*Gra m - (a naerobes) – putative of PD
*The deeper the disengagement of the attachment, the
more concentrated a naerobes would be a t the bottom of
the pocket
- Compl ex s ubgingival microbiota
- Sa mple taking
*Res earch done i n contained environment, controlled
l a bs (hypobaric – l ow a mbient air pressure)
- Di fficulties in cultivation
- Di s ease a ctivity
*The l ess research, the less understanding of the disease
- Pos s ibility of multiple disease i n a subject
*Ca rdi ac probs, endocrine probs (in females), diabetes
 PERIODONTOLOGY | MIDTERMS
DEA 16-17 | HARA, MARIKO D.

100 years of periodontal microbiology (INCOMPLETE ) Virulence factor / antigen Functional or immune
1970 Specific 1990 characteristics
A. viscosus Leukotoxin Lys i s of monocytes / PMN,
Spirochete (ANUG) T-cel ls
A. *predominance in anaerobes
actinomycetemcomitans Li popolysaccharide (LPS) Sti mulate cytokine IL-1, TNF-α,
IL-6, IL-8 a nd PGE-2 release
1930 Non-specific
from hos t cells; induce bone
(Mixed culture)
os teoclastic a ctivity
Fusiform
Immunosuppressive fa ctors Immunosuppression of Th cells
Spirochetes
a nd down-regulate cytokine
Bacteroides
production
1890 Specific SF1 Inhibits T cell proliferation
Amoeba Va ri ous compounds and Inhibitors of PMN l eukocyte
Spirochetes protei ns functi on
Fusiforms
Streptococci Porphyromonas gingivalis
- 37-63% of l oca lized a ggressive periodontitis (majority;
cohos ts)
Non-specific plaque hypothesis
- Predominant in generalized aggressive chronic
- Infections i n pockets are multibacterial
peri odontitis
Specific plaque hypothesis - 40-100% hi gher proportion i n deep than in s hallow
- Progres sion of destructive periodontal disease peri odontal pocket
Virulence factor / antigen Functional or immune
- Aggrega tibacter actinomycecomitan, P. gi ngivalis, P.
characteristics
i ntermedia, T. dentic a re major etiological a gents i n
Li popolysaccharide (LPS) Si gnificant cytotoxin; inducer of
des tructive periodontal disease (G -) s everal host-derived cyto- a nd
chemokines
Virulence
Fi mbriae Sti mulate bacterial attachment
- Abi l ity of microorganism to cause disease to hos t cells or ti ssues;
- Interferes with the function of the host (host response) necessary for ba cterial i nvasion
- Abi l ity of microbe to express pathogenicity to hos t cells
Protei nases (Gingipains) Ti s sue i nvasion a nd destruction
Virulence factor by ba cteria; a poptotic cell death
a nd disruption of PMN
- Promotes colonization and persistence i n the oral cavi ty
functi ons
(a ntibiotic resistance)
- Interfere with host defences Prevotella intermedia
- Des troy host tissue
- Chroni c periodontitis
- Inhibits host repair a nd tissue
- Aggres sive periodontitis
- Puberty-a ssociated gi ngivitis
 Gr (+) Lipoteichoic Acid (LTA)
- ANUG (gi ngivi tis / periodontitis) *seen especially on this*
 Gr (-) Lipopolysaccharide (LPS)
o Vi ra l
A. actinomycetemcomitans o Thrus h / Vincent’s
Prevalence in periodontal disease - Vi rul ence factor
o Gi ngival epithelial cells
- More often in localized aggressive periodontitis
o Protea ses fimbriae
- Acti ve periodontal lesions probing
*Bl eeding – s ign of disease activity Microbial clusters
- Found in increasing periodontal probing depth - Red cl uster – deeper pockets > periodontitis
*7mm a nd beyond you will find AA to be i ncreasing in
- Ora nge cluster – deeper pockets > periodontitis
number
- Green – s hallow pockets > gi ngivitis
- Yel low – s hallow pockets > gi ngivitis
- Purpl e

Red cluster
Supragingival
- Porphyromonas gingivalis
- Ta nnerella forsythia
- Treponema denticola,
T. s ocra nskii
- Euba cterium nodatum
Orange cluster
Supragingival
- Ca mpyl obacter showae,
C. rectus , C. gra cilis
- Fus obacterium nucleatum,
F. vi centii, F. periodonticum,
F. pol ymorphum
- Prevotel la i ntermedia,
P. ni grescens,
P. mel aninogenica
- Gemella morbillorum
- Ca pnocytophaga ochracea
- Sel enomonas noxia
Green cluster
Supragingival
- Ca pnocytophaga sputigena
- Ca pnocytpophaag gingivalis
- Ei kenella corrodens
Yellow cluster
Supragingival
- Streptococcus sp.: S. mitis,
S. ora l is, S. gordonii,
S. s a nguinis, S. a nginosus,
S. i ntermedius, S. constellatus
- Leptotri chia buccalis
- Propi onibacterium a cnes
- Euba cterium saburreum
- Peptos treptococcus micros
- Aggrega tibacter
a cti nomycetemcomitans
PERIODONTOLOGY | MIDTERMS
DEA 16-17 | HARA, MARIKO D.
Purple cluster
Subgingival Supragingival Subgingival
- Porphyromonas gingivalis - Vei llonella parvula - Vei llonella parvula
- Ta nnerella forsythia - Nei sseria mucosa - Acti nomyces odontolyti cus
- Treponema denticola
- Acti nomyces vi scosus
- Sel enomonas noxia
- Aggrega tibacter
a cti nomycetemcomitans
s erotype b
Subgingival
- Prevotel la i ntermedia,
P. ni grescens
- Peptos treptococcus micros
- Ca mpyl obacter gracilis,
C. rectus , C. s howae
- Fus obacterium nucleatum,
F. vi centii, F. periodonticum,
F. pol ymorphum
- S. Cons tellatus
- Euba cterium nodatum
Subgingival
- Ei kenella corrodens
- Ca pnocytophaga gingivalis,
C. s putigena, C. ochracea,
C. conci sus
- Aggrega tibacter
a cti nomycetemcomitans
s erotype a
Subgingival
- Streptococcus sp.: S. mitis,
S. ora l is, S. sanguinis,
S. gordonii, S. i ntermedius
 PERIODONTOLOGY | MIDTERMS
DEA 16-17 | HARA, MARIKO D.

Supragingival calcular deposits Subgingival calcular deposits Dental calculus

- Ma y not come up with a -
Di s engagement of *s ta rted from a plaque biofilm which is easily discernible and
hos t response a tta chment on CEJ removed, so it means that the status of oral hygiene of the px
- Endogenous within the px - Through time, due to jus t presents itself = more calcular deposits, less aware the px
- Sta rts as a biofilm, so i t’s a ca l cium deposition within *common misdiagnosis: i f AG is still intact = no l oss of
s oft a ccumulation a round s a liva, i t hardens in a tta chment, distention only
the crevi ce cons istency
Supragingival calculus
- Ea s ily s calable - Non removal, more
- Corona l to gingival margin
a ccumulation, it comes up
- Whi te or whitish yellow with a hard clay-like consistency
wi th a different color
- Bucca l s urfaces of maxillary molars; l ingual s urfaces of
compl ex from white >
ma ndibular anterior teeth
da rkened
- Deeper pockets, more
Clinical implication
concentrated gra m - Pl a que, ra ther than calculus, provides the pathogenic
nega tive or a naerobe potential
*yel l ow and green complexes – s hallow pockets (0, 1, 2, 3mm) - A s i gnificant a ssociation between ca lculus presence a nd
*s emi-shallow pockets (4, 5mm) gi ngival recession
*ora nge a nd red complexes – s ubgingival (6mm)
Subgingival calculus
Periodontal pathogens associated with health - Bel ow crest of the marginal gingival
- Few l ayer of predominantly gra m positive cocci - Dense, dark brown or greenish black, and hard or flint-
- Gra m positive rods a nd filaments l i ke in consistency
- Very few gra m negative cocci *fl i nt-like – “pa rang pinupulbo”
- Ol der s ubjects - Provi des an ideal environment for bacterial adhesion
*s oft plaque within porous cementum – “nanunuot”
Periodontal pathogens associated with gingivitis
*remove i t by using curette (longer s hank that can reach
- More orga nized dental plaque
6mm a nd beyond pockets)
*more ma ture = concentrations of gram + a nd -
*s upra is removed, chunky s ub is removed, but flint-like
*gra m positive rods a nd filaments increases
on the cementum is not removed, tissue reattached but
*a na erobic bacteria appear
ni dus i s still there: no oxygen, in favor of gram negative
Periodontal pathogens associated with periodontitis
Clinical implication
 Sl i ght chronic periodontitis
- As s ociated with higher rate of progression of the
- P. gi ngivalis
peri odontal lesion
- T. fors ythia
- Si gnificant association with gingival inflammation
 Modera te and advanced adult chronic periodontitis
- The exa ct role in the initiation a nd progression of the
- P. gi ngivalis
peri odontal lesion is still unclear
- P. i ntermedia
- T. fors ythia PD = ba cterial plaque i nitiation + host response s usceptibility
- T. denticola (forma tion of biofilm)
- A. a cti nomycetemcomitans *even i n the presence of a ll the biofilms, if the px is not
- Fi l ifactor alocis predisposed, there will be no effect
- Porphyromonas
Pathogenesis of PD
Periodontal pathogens associated with peri-implantitis
Plaque biofilm
- Si milar to chronic a dult periodontitis but without
peri odontal ligament
- P. gi ngivalis Response to bacterial challenge
- P. i ntermedia
- Prevotel la nigrescens Host immune-inflammatory response
- Ta nnerella forsythia
- C. rectus Destruction of periodontal tisue
- A. a cti nomycetemcomitans
 PERIODONTOLOGY | MIDTERMS
DEA 16-17 | HARA, MARIKO D.

Summary  Dendritic cells (antigen

- Ba cterial plaque is the ca use of PD i n s usceptible pres enting cells) –
i ndividuals membrane receptors i n
- Ca l culus by i tself does not produce PD the form of l igands
- There a re specific bacteria a ssociated with health and (mol ecular proteins)
di s eased s tate of the periodontium  La ngerhans (epithelial
cel ls)
Host response and periodontal disease  Na tura l killer cells
 Ba cteria is essential but not sufficient to form peri odontal
di s ease

- Host factors (heredity)

*i nnate genetic ma keup
*a ggressive form of PD
- Environmental factors
*s oci oeconomic status – ci garette becomes their
nutri tion
*di et – hi gh a mount of refined sugar
- Acquired risk factors (stress, smoking)
a re equally a s i mportant as determinants of disease
occurrence a nd severity of cl inical outcome

 The host s ystem that provides protection and defense

vi rtua lly results in some form of destruction (double-edged
s word)
*i nflammation = i mbalance i n host response mechanism;
mea ning i f there is an insult s uch as plaque formation, the
body i s predisposed to plaque composition then the state of
hea lth ca n actually promote inflammation, then if you have
s i gns a nd s ymptoms of i nflammation, you now release a
chemi cal i mbalance i n the form of your i nnate i mmune
res ponse
*da mage is ca used by the i nflammatory response to the
perceived invader

Players for innate response 3. Primary and secondary lymphoid tissue

1. Anatomical barriers
- Ski n, gingival crevicular epithelium (sloughing off of
epi thelial cells)
2. Inflammatory cells
Innate immune response
- Infl ammatory cells contained
wi thin CT l ayer
 Neutrophils / PMNs
(pri mary s oldier cells)
 Ma crophages
 Lymphocytes (activated in
a cute a nd more so in
chroni c lesions)
 Ma s t cells (for histamine)
 Eos i nophils
 Ba s ophils
Adaptive immune response
- Humoral: B-cells –
Immunoglobulins
a cti va ted > a ntibodies
crea ted
- Cel l -mediated: T-cells
- Where i nflammatory cells came from
4. Antibodies
5. Physiologic pH
- Any condi tion that may a lter the pH and temperature >
wi l l make or break antigen
*a l l of these are i nitiated by cytokines (molecules that have to be
emi tted within the wound and so a ll blood cells must go through
endothelial lining)
1. Defense mechanism
- Ini tial va soconstriction (blood clotting factors)
2. Chemical signals
- Pros ta glandin (pro-inflammatory)
3. Diapedesis
- Mol ecular a ttraction = a dhescence
4. Chemotaxis
 PERIODONTOLOGY | MIDTERMS
DEA 16-17 | HARA, MARIKO D.

 Neutrophils are a two-edged sword  Random burst model

- The good: neutrophils play a ma jor role in controlling
s ubgingival plaque bacteria by phagocytosis and
mi crobial killing
- The bad: proteolytic enzymes released by neutrophils
da mage periodontal tissues
- The ugly: neutrophils when they a re in large numbers can
form hi ghly destructive a bscesses
- Si tes may s how no a ctivity or s ites ma y show one or
s everal bursts of a ctivity
 Asynchronous multiple burst model
- Repeated bursts over a finite period of ti me followed by a
prol onged period of i nactivity

 Before the 1980’s, periodontitis was thought to be

universally prevalent i n humans by the time a person
rea ches middle a ge a nd all preventive measures were
di rected at controlling the bacterial challenge

 Results by Loe et al
- Al l i ndividuals were not equally a ffected by periodontal
di s ease
- 81% modera te progression in attachment l oss
- 11% di d not progress beyond gingivitis
- 8% exhi bited ra pid loss of attachment
*a ggressive PD

 Conclusions of Loe et al
- Al though gingivi tis may present at a n early s tage in the
na tural course of periodontitis, it may a lso be a separate  Overview of host response
di s ease entity, which i n some patients will not progress - Gi ngivitis is initiated by mi crobial pathogen
- It a ppears that prevalence in PD that is severe enough to - In mos t individual disease is limited
crea te tooth loss is lower tha n originally believed

 Characteristics of adaptive immunity

 Periodontology 2000
- “Peri odontitis is not a single disease entity, but a family
- Produces specific response a gainst antigen; s econd line of
defense (memory cells created)
of cl os ely related diseases that va ry i n etiology, natural
hi s tory a nd response to therapy”
 Characteristics of innate immunity
- A common underlyi ng chain of events i n pathogenesis…
- Nons pecific / congenital responses against a ntigen
 Models of disease progression
 Complement of nonspecific immunity
- Tra di tional concept of disease: continuous progression
model - PMNs – pha gocyti c cells
- Pl a que > gi ngivitis > periodontitis - Monocytes / macrophages (MO) – pres ent antigens of
pha gocyti c MOs
 Classic model of CIPD progression - Natural killer cells (NK)

- Sl ow destruction of attachment - Complement

- Bone resorption - Acute phase proteins (c-reactive protein)
*bl ood tests: i f this is elevated, there is a risk that a px
- Eventual l oss of teeth
s uffering from heart disease may also be s uffering from
peri odontitis and vi ce versa
 Burst model *composition of plaque within crevice is same
- Di s ease pathogenesis in s hort composition of bacteria in atherosclerosis
*epi sodes of signs and symptoms tapos mawawala
- Inflammatory mediators – eg. Bra dykinin, pro-
*pwedeng merong intervention, pwedeng wala i nflammatory cytokines, prostaglandins
 PERIODONTOLOGY | MIDTERMS
DEA 16-17 | HARA, MARIKO D.

 Complement
- Compl ement factors C1-C9 ci rculate in the blood
- Protei n processing enzyme functions
- 2 pa thway activations: classical and alternate
- Chemotactic a ctivity: C5a s tronger than C2a
- C3b ops onizes first, followed by C5b, etc.
- Pore forma tion i s bactericidal through the MAC

Life cycle of PMN

Cytokines
Interleukins (IL) Cytotoxi c fa ctors Interferon
Pro-i nflammatory TNF a INF ga mma
- IL – 1a /b, 2, 3,
4, 5, 6, 7, 12
Anti -inflammatory
Life cycle of macrophage - IL – 10, 11, 13
Chemotactic
- IL – 8, 9
Growth fa ctors Col ony s timulating factors
Anti -inflammatory
- TGF a , b
- EGF, FGF - G-CSF
- Pl a telet derived - M-CSF
- BMPs - GM-CSF
- Ins ulin like - Mul ti -CSF = IL3
PERIODONTOLOGY | MIDTERMS
DEA 16-17 | HARA, MARIKO D.