Positive correlation between the proportions of subgingival spirochetes and motile bacteria and susceptibility of human subjects to periodontal deterioration

Guided tissue regeneration and orthodontic movement for the treatment of pathological migration in esthetic zone

Pathological migration is one of the chief complaints of patients-seeking dental treatment. It results in difficulty in mastication, speech, poor esthetic appearance, and decreased self-confidence. The prevalence ranges from 21.73% to 55.8% in patients having moderate-to-severe periodontitis. In this presentation, a 38-year-old adult male, systemically healthy, nonsmoking presented with the complaint of mobility and forward displacement of maxillary anterior tooth causing poor esthetic appearance and low self-esteem. He was treated with the interdisciplinary approach of periodontal and orthodontic intervention. Two-year posttreatment follow-up shows significant improvement in esthetics, periodontal status, and boosted the self-confidence of the patient and improved the oral health-related quality of life. This case emphasizes the importance of regenerative therapy and orthodontic movement for the treatment of periodontally compromised pathologically migrated tooth in adult patient.

Salivary Microbiome Profile of Diabetes and Periodontitis in a Chinese Population

Aim

There is a bidirectional association between diabetes and periodontitis. However, the effect of diabetes on the periodontitis salivary microbiota has not been elucidated. The aim of this study was to determine the effect of the presence of diabetes on the microbiota among Chinese patients with periodontitis.

Materials and Methods

Unstimulated whole saliva samples were collected from the periodontitis with diabetes group (TC), chronic periodontitis group (CP), and periodontally healthy and systemically healthy group (H) by spitting method. Bacterial genomic DNA was PCR-amplified at the V4 variable region of 16S rRNA gene. The library was constructed according to the obtained sequence results, and biological analysis and statistical analysis were carried out. Functional prediction of three groups of microbial communities was performed by the PICRUSt algorithm.

Results

There was no significant difference in bacterial diversity between the TC and CP groups. Compared with the H group, the TC group and CP group presented a higher diversity of salivary flora. Firmicutes, Streptococcus, Haemophilus, Veillonella, and Haemophilus parainfluenzae dominated the H group. Corynebacterium, Leptotrichia, Dialister, Comamonas, Capnocytophaga, Catonella, Filifactor, Campylobacter, Treponema, Campylobacter concisus, Prevotella oralis, and Porphyromonas gingivalis were significantly enriched in the TC and CP groups. Among them, Treponema and P. oralis were the most abundant in the TC group. The PICRUSt results showed that many pathways related to cell motility and functional metabolism of the salivary microbial flora changed in the TC group and the CP group.

Conclusions

Diabetes was not the main factor causing the altered diversity of salivary microbiota in patients with periodontitis; however, the presence of diabetes altered the abundance of some microbiota in saliva.

Positive stain for light and electron microscopic demonstration of spirochetes in subgingival plaque and crevicular fluid samples from periodontal diseased sites

In a recent study of 400 subgingival plaque samples from over 110 adult periodontitis patients, spirochetes were the overwhelming microbial type, averaging about 45% of the microbial count. This finding supports earlier arguments that spirochetes are pathognomonic in periodontal disease. Other studies had shown clear-cut differences in the microbial composition of healthy and diseased subgingival sites — the proportion of spirochetes being significantly higher in the latter. Another study indicated that periodontal deterioration at these sites could be predicted better by increased proportions of motile rods and spirochetes than by clinical measurements. However, spirochetes of all sizes and species do not show the same degree of association with periodontal breakdown. Moreover, spirochetes are usually difficult to culture and stain; they are generally monitored by darkfield or phase contrast microscopy.

The PATS reaction, a modified periodic acid-Schiff(PAS) reaction which deposits silver for light and electron microscopy appears to stain Gram(-) bacteria positively as well as neutrophils and activated macrophages. When studying the stained Gram(-) bacteria on coverslip smears of subgingival plaque or crevicular fluid samples of patients by light microscopy, varying numbers of intensely stained spirochetes of different sizes were observed (Figs. 1,2). More spirochetes were usually seen in samples from diseased sites. After drying replicate PATS-stained coverslips with hexamethyldisilazane they were sputter coated with gold, and. then examined by the SEI and BEI modes of scanning electron microscopy (Figs. 3-6). A permanent record of the proportions of large, medium and small spirochetes at each site could thus be obtained. Generally, greater numbers of gram negative bacteria including some spirochetes were stained in samples from diseased sites. At some sites, however, spirochetes were the predominant microbes in both crevicular fluid and subgingival plaque (Fig. 1).

Clinicomicrobiological evaluation of the efficacy of local delivery of moxifloxacin and ibuprofen gel as an adjunct to scaling and root planing in chronic periodontitis patients

Aims:

To evaluate the clinical and microbiological effects of local drug delivery of moxifloxacin and ibuprofen gel as an adjunct to conventional periodontal therapy in chronic periodontitis patients.

Subjects and Methods:

Twenty patients with moderate-to-severe chronic generalized periodontitis with probing pocket depth (PPD) of ≥5 mm and <8 mm were randomly assigned to one of the following two treatment modalities: scaling and root planing (SRP) group and moxifloxacin and ibuprofen combination gel as an adjunct to SRP group. Clinical parameters include plaque index (PI), gingival index (GI), probing depths and clinical attachment level (CAL) that were recorded at baseline and 1 and 3 months after the treatment, and microbiologic assessment was done using dark-field microscopy.

Results:

A statistically significant difference in mean PI and GI scores and reduction in PPD and gain in CAL were observed at different study intervals with greater difference in the test group. On microbiological examination, the percentage of cocci increased, while a statistically significant decrease in the mean percentage of bacilli and spirochetes was observed in both groups at given intervals. In-vitro dissolution showed controlled release of both the drugs.

Conclusions:

Among the two treatment modalities, treatment with moxifloxacin and ibuprofen local delivery as an adjunct to SRP gave superior results in clinical and microbiological parameters compared to SRP group.

Introduction to Clinical Microbiology for the General Dentist

Clinical oral microbiology may help dental professionals identify infecting pathogenic species and evaluate their in vitro antimicrobial susceptibility. Saliva, dental plaque biofilms, mucosal smears, abscess aspirates, and soft tissue biopsies are sources of microorganisms for laboratory testing. Microbial-based treatment end points may help clinicians better identify patients in need of additional or altered dental therapies before the onset of clinical treatment failure, and help improve patient oral health outcomes. Microbiological testing appears particularly helpful in periodontal disease treatment planning. Further research and technological advances are likely to increase the availability and clinical utility of microbiological analysis in modern dental practice.

Learned and unlearned concepts in periodontal diagnostics: a 50-year perspective

In the past 50 years, conceptual changes in the field of periodontal diagnostics have paralleled those associated with a better scientific understanding of the full spectrum of processes that affect periodontal health and disease. Fifty years ago, concepts regarding the diagnosis of periodontal diseases followed the classical pathology paradigm. It was believed that the two basic forms of destructive periodontal disease were chronic inflammatory periodontitis and 'periodontosis'- a degenerative condition. In the subsequent 25 years it was shown that periodontosis was an infection. By 1987, major new concepts regarding the diagnosis and pathogenesis of periodontitis included: (i) all cases of untreated gingivitis do not inevitably progress to periodontitis; (ii) progression of untreated periodontitis is often episodic; (iii) some sites with untreated periodontitis do not progress; (iv) a rather small population of specific bacteria ('periodontal pathogens') appear to be the main etiologic agents of chronic inflammatory periodontitis; and (v) tissue damage in periodontitis is primarily caused by inflammatory and immunologic host responses to infecting agents. The concepts that were in place by 1987 are still largely intact in 2012. However, in the decades to come, it is likely that new information on the human microbiome will change our current concepts concerning the prevention, diagnosis and treatment of periodontal diseases.

Treponema denticola interactions with host proteins

Oral Treponema species, most notably T. denticola, are implicated in the destructive effects of human periodontal disease. Progress in the molecular analysis of interactions between T. denticola and host proteins is reviewed here, with particular emphasis on the characterization of surface-expressed and secreted proteins of T. denticola involved in interactions with host cells, extracellular matrix components, and components of the innate immune system.

Bone microbial contamination influences autogenous grafting in sinus augmentation

BACKGROUND

The oral occurrence of putative microbial pathogens in humans has been documented in health and disease. The presence of periodontopathogens in patients with a history of periodontal disease may have a negative impact on bone regeneration. This investigation was conducted to confirm the presence of periodontal pathogens in bone particles harvested intraorally for maxillary sinus augmentation and to assess the clinical and radiographic outcomes 6 to 12 months after bone augmentation.

METHODS

Culture and polymerase chain reaction (PCR)-based identification were performed by paper-point sampling of intraorally harvested bone particles in a group of 12 maintenance patients undergoing maxillary sinus augmentation. Radiographs were taken to assess and compare bone healing and volume gain at baseline and at 6 to 12 months after augmentation.

RESULTS

The presence of periodontal pathogens (Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans [previously Actinobacillus actinomycetemcomitans], Prevotella intermedia, Tannerella forsythia [previously T. forsythensis], Fusobacterium nucleatum, Parvimonas micra [previously Peptostreptococcus micros or Micromonas micros], Campylobacter rectus, enteric Gram-negative rods, and Dialister pneumosintes) was identified in 10 of 12 patients (83%) by culture, PCR, or both and was associated with greater bone volume loss at 6 months postaugmentation. The PCR-positive triad, P. gingivalis, A. actinomycetemcomitans, and P. intermedia, was associated with pronounced volume loss of the grafted sinus at 6 months.

CONCLUSIONS

To the best of our knowledge, this is the first study to confirm osseous microbial contamination with major periodontopathogens in individuals undergoing maxillary sinus augmentation with a history of periodontitis. The effect on the grafting outcome translated into bone volume loss in the grafted sinus 6 months postaugmentation. Specific microbial contamination may have an impact on osteogenesis in osseous regeneration.

Laboratory maintenance of Treponema denticola

This unit describes the methods, media, and equipment necessary for routine laboratory culture and handling of the anaerobic oral spirochete Treponema denticola. Topics discussed include nutrient requirements, recommended media formulations, and expected growth kinetics, as well as methods and equipment necessary to maintain anaerobic conditions. An additional protocol on isolation of T. denticola from clinical samples is included.

Molecular epidemiology of oral treponemes in patients with periodontitis and in periodontitis-resistant subjects

The etiologic role of oral treponemes in human periodontitis is still under debate. Although seen by dark-field microscopy in large numbers, their possible role is still unclear since they comprise some 60 different phylotypes, most of which are still uncultured. To determine their status as mere commensals or opportunistic pathogens, molecular epidemiological studies are required that include both cultured and as-yet-uncultured organisms. Here we present such data, comparing treponemal populations from chronic periodontitis (CP) or generalized aggressive periodontitis (GAP) patients. As a periodontitis-resistant (PR) control group, we included elderly volunteers with more than 20 natural teeth and no history of periodontal treatment and no or minimal clinical signs of periodontitis. Almost every treponemal phylotype was present in all three groups. For most treponemes, the proportion of subjects positive for a certain species or phylotype was higher in both periodontitis groups than in the PR group. This difference was pronounced for treponemes of the phylogenetic groups II and IV and for Treponema socranskii and Treponema lecithinolyticum. Between the periodontitis groups the only significant differences were seen for T. socranskii and T. lecithinolyticum, which were found more often in periodontal pockets of GAP patients than of CP patients. In contrast, no difference was found for Treponema denticola. Our findings, however, strengthen the hypothesis of treponemes being opportunistic pathogens. It appears that T. socranskii, T. lecithinolyticum and group II and IV treponemes may represent good indicators for periodontitis and suggest the value of the respective probes for microbiological diagnosis in periodontitis subjects.

Surface protease of Treponema denticola hydrolyzes C3 and influences function of polymorphonuclear leukocytes

Treponema denticola is a dominant microorganism in human periodontal lesions. One of the major virulence factors of this microorganism is its chymotrypsin-like surface protease, dentilisin. The purpose of this study was to evaluate the effect of dentilisin on human polymorphonuclear leukocytes (PMNs). We used chemiluminescence to assess production of O(-)(2) by PMNs against T. denticola ATCC 35405 and dentilisin-deficient mutant K1. T. denticola ATCC 35405 induced production of O(-)(2), whereas dentilisin-deficient K1 did not. We found that chymostatin, a protease inhibitor, strongly reduced the ability of T. denticola ATCC 35405 to induce production of, O(-)(2), whereas K1 was relatively unaffected. We also used Immunoblot and ELISA to evaluate the activation of complement by this microorganism in relation to PMNs. T. denticola ATCC 35405 hydrolyzed the alpha-chain of C3, producing iC3b. Furthermore, strain ATCC 35405 induced a larger release of MMP-9 from PMNs than strain K1. Dentilisin activated PMNs via complement pathways and may play a role in establishing periodontal lesions.

Intraoral dissemination of treponemes after periodontal therapy

Oral treponemes are related to chronic periodontitis, but the effect of periodontal therapy on the majority of treponemal species is unknown. The aim of this prospective study was to evaluate the dynamics in prevalence profiles of treponemes in different habitats of the oral cavity. Thirty-five patients with chronic periodontitis were randomly assigned to mechanical debridement alone (control group) or systemic amoxicillin/metronidazole plus chlorhexidine (test group). Subgingival and mucous membrane plaque samples were taken at baseline, after 10 days, and during supportive periodontal therapy at 3, 6, 9, 12, 18, and 24 months. T. denticola, T. lecithinolyticum, T. maltophilum, T. socranskii, T. vincentii, and treponemal phylotypes I-VII were detected using polymerase chain reaction (PCR) and dot blot analysis. For the majority of the assessed treponemes, a significant intragroup increase in prevalence in the different habitats ( P<0.05) occurred over the study course but, compared to debridement alone, adjunctive antimicrobial therapy resulted in a nonsignificant trend toward lower prevalence in the subgingival habitat. In no case were treponemes eradicated from the oral cavity. After both therapies, possibly new infection with and/or dissemination of Treponema ssp. occurred, which led to treponemes recovering in different habitats and to increased intraoral prevalence. The prescribed adjunctive antimicrobial therapy may limit this increase in the subgingival region.

Does professional preventive care benefit from additional subgingival irrigation?

The effect of an oral irrigator (Water Pik, Intersante) with a subgingival tip (Pik Pocket Subgingival Tip, Intersante) in the reduction of gingivitis was investigated in a single-blind three-group study involving 45 volunteers (age 46.2+/-10.2). All volunteers (inclusion criteria: gingivitis or a superficial periodontitis) were examined and underwent professional tooth cleaning at the first appointment. They were then randomly distributed in three groups: one group used the irrigator with the subgingival tip once daily with just tap water, in addition to their regular oral hygiene; another group also used an herbal-based mouth rinse (Parodontax, GlaxoSmithkline) in the water of the irrigator; a third group did not use an irrigator or any irrigant and therefore served as control. All groups received professional oral care education at each appointment. The investigation period was 3 months. At baseline and after 4, 8, and 12 weeks, the plaque index (PI, scores 0-5), gingival index (GI, scores 0-3), bleeding index (BI scores 0-5), and sulcus fluid flow rate (SFFR, Periotron 6000) at the Ramfjord teeth were scored. At baseline and after 3 months, the probing depth (millimeters) was measured at six surfaces of all teeth. A significant reduction in BI, PI, GI, probing depth, and SFFR was observed within 3 months. With all volunteers, however, there was no statistically significant difference ( p>/=0.05, Wilcoxon-test, SAS 6.04) between the three groups at any time. The additional use of the Water Pik irrigator with the Pik Pocket subgingival irrigation device with or without an herbal mouth rinse showed no clinical benefit over professional education in oral hygiene alone.

Detection and Prediction of Tooth Mobility During the Periodontitis Healing Process

The focus of the article is on a generic approach to prediction of a healing process based on automatic measurement and modelling of mechanical disease indicators. As a specific example the healing process after treatment of advanced periodontitis is characterised and predicted based on measurement of tooth mobility (TM). For the measurement a new mechatronic instrument was developed that includes a pneumatically driven probe with incorporated sensors of tooth displacement and loading force. TM is measured by a computer controlled data acquisition system and predicted by a non-parametric regression. Similarly as in the characterisation of technical processes, a measured sample is described by TM time series detected on a particular patient, while the regression is determined by a set of samples obtained from a group of patients following periodontal therapy. The influence of surgical access therapy and systemic administration of metronidazole as an adjunct to the mechanical treatment is demonstrated. For this purpose the average changes of tooth mobility are determined on variously treated subgroups. A new method of healing process prediction is demonstrated and its performance is described by a prediction quality.

Binding ofPorphyromonas gingivalisfimbriae toTreponema denticoladentilisin

Treponema denticola has been reported to coaggregate with Porphyromonas gingivalis and localize closely together in matured subgingival plaque. In this study of the interaction of T. denticola with P. gingivalis, the P. gingivalis fimbria-binding protein of T. denticola was identified by two-dimensional electrophoresis followed by a ligand overlay assay with P. gingivalis fimbriae, and was determined to be dentilisin, a chymotrypsin-like proteinase of T. denticola. The binding was further demonstrated with a ligand overlay assay using an isolated GST fusion dentilisin construct. Our results suggest that P. gingivalis fimbriae and T. denticola dentilisin are implicated in the coaggregation of these bacteria.

Periodontal concerns associated with the orthodontic treatment of impacted teeth

Impacted teeth are common and are often treated with orthodontic eruption, but periodontal problems associated with the process can evade detection. Profound destruction of the periodontium of an impacted tooth or adjacent teeth can occur. This case report describes the orthodontic eruption of 4 impacted canines in a 19-year-old woman. An open surgical approach was used. Within 6 months of treatment, the maxillary right canine and the lateral incisor experienced severe periodontal destruction, resulting in questionable prognoses for the teeth. Plaque control, periodontal architecture, and subgingival microflora were examined as local etiologic factors of periodontal destruction associated with orthodontic eruption of impacted teeth. Plaque control measures were evaluated, and the consequences of orthodontic tooth movement in the presence of inadequate plaque control were considered. Areas of periodontal architecture made vulnerable by the surgical exposure of the impacted teeth were identified, and the effect of orthodontic force on the periodontium was explored. An increase in putative periopathogens in the subgingival microflora after orthodontic appliance placement was observed. Microbiologic monitoring for pathologic levels of periopathogens and antibiotic therapy were considered. Orthodontic treatment of impacted teeth might require additional professional and personal plaque control measures, 3-dimensional diagnostic imaging, and control of putative periopathogens to preserve the health of the periodontium.

Role of Treponema denticola in periodontal diseases

Among periodontal anaerobic pathogens, the oral spirochetes, and especially Treponema denticola, have been associated with periodontal diseases such as early-onset periodontitis, necrotizing ulcerative gingivitis, and acute pericoronitis. Basic research as well as clinical evidence suggest that the prevalence of T denticola, together with other proteolytic gram-negative bacteria in high numbers in periodontal pockets, may play an important role in the progression of periodontal disease. The accumulation of these bacteria and their products in the pocket may render the surface lining periodontal cells highly susceptible to lysis and damage. T. denticola has been shown to adhere to fibroblasts and epithelial cells, as well as to extracellular matrix components present in periodontal tissues, and to produce several deleterious factors that may contribute to the virulence of the bacteria. These bacterial components include outer-sheath-associated peptidases, chymotrypsin-like and trypsin-like proteinases, hemolytic and hemagglutinating activities, adhesins that bind to matrix proteins and cells, and an outer-sheath protein with pore-forming properties. The effects of T. denticola whole cells and their products on a variety of host mucosal and immunological cells has been studied extensively (Fig. 1). The clinical data regarding the presence of T. denticola in periodontal health and disease, together with the basic research results involving the role of T. denticola factors and products in relation to periodontal diseases, are reviewed and discussed in this article.

Sulfate-reducing bacteria in relation with other potential periodontal pathogens

BACKGROUND, AIMS

Oral sulfate-reducing bacteria are involved in several clinical categories of periodontitis. The aim of this cross-sectional study was to compare the presence of sulfate-reducing bacteria (SRB) with other putative pathogens including spirochetes, Actinobacillus actinomycetemcomitans, Bacteroides forsythus, Porphyromonas gingivalis, and Treponema denticola in periodontal lesions.

METHOD

Periodontal SRB were detected by enrichment culture and compared with a microscopic spirochete count (n=168). Species-specific oligonucleotide probes directed against the 16S rRNA were employed to determine the presence of A. actinomycetemcomitans, P. gingivalis, B. forsythus, and T. denticola (n=55).

RESULTS

A significant positive correlation was observed between the presence of SRB and the proportions of spirochetes in subgingival plaque, although the 2 bacterial groups also occurred separately. SRB tended to be negatively correlated with the presence of A. actinomycetemcomitans. In contrast, all pockets with SRB harbored either T. denticola, or both T. denticola and B. forsythus (12/14) before therapy. Interestingly, the combination of SRB with P. gingivalis occurred in 32% of the periodontal pockets before treatment. After initial periodontal therapy, the prevalence of this combination was reduced to 2% of the sites, and to 25% of the sites in recall patients.

CONCLUSION

The presence of SRB was positively correlated with T. denticola, B. forsythus, and P. gingivalis in periodontal lesions. These suspected pathogens form a complex strongly associated with destructive periodontitis.

Effects of whole cell sonicates of Treponema lecithinolyticum on osteoclast differentiation

BACKGROUND

Alveolar bone destruction is a characteristic feature of periodontal diseases and multinucleated osteoclast cells derived from hemopoietic cells are responsible for bone resorption. Treponema lecithinolyticum is a novel oral spirochete isolated from the periodontal lesions.

METHODS

The effect of whole cell sonicates on the osteoclast differentiation was examined in a co-culture system of hemopoietic mouse bone marrow cells and calvaria derived-osteoblastic cells to clarify the role of T. lecithinolyticum in the alveolar bone destruction associated with periodontal diseases. The differentiated osteoclasts were confirmed by tartrate-resistant acid phosphatase (TRAP) staining.

RESULTS

Sonicates of this bacterium stimulated the osteoclast formation in the co-culture system in a dose-dependent manner. The sonicates-induced osteoclast formation was partially inhibited by the heat treatment of sonicates. Indomethacin, which is a prostaglandin inhibitor, decreased the osteoclast formation induced by the bacterial sonicates.

CONCLUSIONS

These findings suggest that T. lecithinolyticum induces osteoclast differentiation by a prostaglandin E2-dependent mechanism and that heat-labile components may be involved in this process.

Outer sheath associated proteins of the oral spirochete Treponema maltophilum

We recently cloned the major outer membrane protein of Treponema maltophilum [Heuner, K., Choi, B.K., Schade, R., Moter, A., Otto, A., Göbel, U.B., J. Bacteriol. 181, 1025-1029]. Here we report the localization of the major sheath protein (Msp)A protein in T. maltophilum by immunogold electron microscopy and its expression. Northern blot analysis revealed that mspA is expressed constitutively as a monocistronic unit. The transcription initiation site of the mspA gene was identified by primer extension analysis. A further screening of a genomic library of T. maltophilum with an anti-outer membrane fraction antibody was done. We were able to clone DNA regions of T. maltophilum encoding putative sugar transport operons and putative outer membrane proteins of this oral treponeme which has a high prevalence in periodontal lesions.

Features of severe periodontal disease in a teenager with Chédiak-Higashi syndrome

BACKGROUND

Chédiak-Higashi syndrome (C-HS) is a rare congenital disease characterized by defective neutrophil function with abnormal lysosomal inclusions, neutropenia, and reduced chemotaxis. The complete syndrome includes oculocutaneous albinism with photophobia, neurologic features, recurrent infections, and enterocolitis.

METHODS

A 14-year-old male C-HS patient was referred to us because of serious periodontal destruction with acute inflamed gingiva and ulcers. Clinical and biological investigations were performed, leading to the diagnosis of C-HS.

RESULTS

Laboratory findings included neutropenia and hypergammaglobulinemia. Peripheral blood smears showed giant granules in neutrophils, eosinophils, and granulocytes. Bone marrow smears showed giant inclusions in leukocyte precursor cells. These granules and inclusions were characteristic of Chédiak-Higashi syndrome. Oral radiographic status showed extensive loss of alveolar bone leading, in most cases, to tooth exfoliation. Bacteria often associated with periodontitis were detected in subgingival plaque samples, including Fusobacterium nucleatum, Campylobacter rectus, Prevotella melaninogenica, Peptostreptococcus anaerobius, and Clostridium sp. Biopsies of periodontal tissues for light and electronic microscopic examinations revealed massive bacterial invasion of the epithelial tissue, epithelial cells, and connective tissue. Ultrastructural observations of periodontal polymorphonuclear leukocytes showed defective granulation, with abnormal granules not discharging their lysosomal content against engulfed bacteria. Viable dividing bacteria were found in the cytoplasm.

CONCLUSIONS

In this case, early-onset periodontitis seems to be the expression of C-HS granulocyte deficiency. Periodontal treatment of these patients is often unsuccessful. This case report illustrates the importance of the dentist in initiating clinical and biological investigations in such early aggressive periodontitis in young patients.

A flagellar gene cluster from the oral spirochaete Treponema maltophilum

A flagellar gene cluster from the oral spirochaete Treponema maltophilum ATCC 51939T was cloned. Sequence analysis revealed six putative ORFs, two of which encode the flagellar subunit proteins FlaB2 (286 aa) and FlaB3 (285 aa). Northern blot analysis revealed two flagellin transcripts with the expected size of monocistronic mRNAs. Sequence analysis and primer extension experiments indicated that the transcription of the flaB2 gene is directed by a sigma28-like FliA factor. Using fliA and fliA+ Escherichia coli K-12 strains, it was shown that flaB2 expression in E. coli required the sigma28 factor using an initiation site identical to that in Treponema maltophilum. Primer extension analysis revealed two transcriptional start sites 5' of the flaB3 gene, a strong promoter with a sigma28-like -10 promoter element and a weak promoter with a putative sigma54 promoter consensus sequence. Downstream of flaB3, a putative fliD homologue was found, probably encoding the flagellar cap protein of Treponema maltophilum. Flagellin-gene-specific DNA probes hybridized to all 13 Treponema strains investigated, whereas a fliD-specific DNA probe only hybridized to Treponema maltophilum, other treponemal group IV isolates and Treponema brennaborense.

Adherence to and penetration through endothelial cells by oral treponemes

Oral spirochetes were co-incubated with monolayers of endothelial cells seeded into multiwell plates or onto filters mounted in plastic chambers. Attachment was assessed using an enzyme-linked immunosorbent assay and scanning electron microscopy. Invasiveness was determined by monitoring media beneath filters within chambers for spirochetes using darkfield microscopy. Transmission electron microscopy was used to estimate intercellular and intracellular passage of spirochetes through monolayers. All tested treponemes attached to monolayers in a dose- and time-dependent manner, except Treponema phagedenis. A few treponemes were observed within host cell cytoplasm. Unidentified spirochetes obtained from dental plaque were also invasive. Results indicate that oral spirochetes possess virulence-associated characteristics shared with pathogenic spirochetes. Further studies should examine the possibility that invasive spirochetes could disseminate from within affected gingiva.

Longitudinal effect of non-surgical treatment and systemic metronidazole for 1 week in smokers and non-smokers with refractory periodontitis: a 5-year study

BACKGROUND

Periodontitis consists of a mixture of diseases, most of which respond favorably to traditional mechanical therapy. It is now recognized that advanced periodontitis does not always respond to conventional management with scaling, periodontal surgery, and oral hygiene measures. However, various types of antibiotics given systemically or locally improve the success rate of periodontal therapy. In short-term studies, it has been shown that metronidazole, when systemically administered after debridement, resulted in treatment benefits including less need for surgical intervention.

METHODS

In this double-blind study, we evaluated periodontal treatment involving initial non-surgical treatment, systemic administration of metronidazole for 1 week, and then follow-ups for scaling and root planing every 6 months, for 5 years. The study population consisted of 64 subjects (37 smokers and 27 non-smokers), mean age 36.3 (+/-3.0 SD) years, with severe periodontal disease. After initial scaling and root planing, patients were randomly assigned to the intervention or placebo groups: 400 mg metronidazole or a placebo administered at 8-hour intervals for 1 week. The participants underwent an extensive clinical periodontal examination. Gingival crevicular fluid (GCF) was analyzed for spirochetes and granulocytes. Samples were cultured for Actinobacillus actinomycetemcomitans (A.a.), Porphyromonas gingivalis (Pg.), and Prevotella intermedia (Pi.).

RESULTS

The number of patients infected with A.a., Pg., Pi., and spirochetes decreased during the study. Most patients who harbored spirochetes at the end of the study had these microorganisms at the beginning. Smokers responded less favorably to periodontal therapy than non-smokers. Non-smoking patients who required only non-surgical therapy in the intervention group showed statistically significant improvement in the clinical parameters after 5 years. Patients with complete healing, defined as the absence of inflamed sites > or =5 mm, after 5 years were found only in the intervention group. The patients considered healthy after 5 years were the same patients found to be healthy after 6 months.

CONCLUSIONS

Decisive factors in the sustained long-term improvement of patients who respond satisfactorily to treatment are probably initial scaling and root planing; a brief course of metronidazole; and regular follow-up examinations at 6-month intervals for oral hygiene and scaling and root planing.

Cloning and characterization of a gene (mspA) encoding the major sheath protein of Treponema maltophilum ATCC 51939(T)

The major sheath protein-encoding gene (mspA) of the oral spirochete Treponema maltophilum ATCC 51939(T) was cloned by screening a genomic library with an anti-outer membrane fraction antibody. The mspA gene encodes a precursor protein of 575 amino acids with a predicted molecular mass of 62.3 kDa, including a signal peptide of 19 amino acids. The native MspA formed a heat-modifiable, detergent- and trypsin-stable complex which is associated with the outer membrane. Hybridization with an mspA-specific probe showed no cross-reactivity with the msp gene from Treponema denticola.

Evidence for a new type of outer membrane lipid in oral spirochete Treponema denticola. Functioning permeation barrier without lipopolysaccharides

A new class of outer membrane lipid (OML) was isolated from the oral spirochete Treponema denticola strain ATCC 33521 using a phenol/chloroform/light petroleum procedure normally applied for lipopolysaccharide extraction. In addition to chemical analysis, Fourier transform infrared (FTIR) spectroscopy was applied to compare the biophysical properties of OML with lipopolysaccharides (LPS) and lipoteichoic acids (LTA). Isolated OML fractions represent 1.4% of the total dry cell weight, are about 4 kDa in size, and contain 6% amino sugars, 8% neutral sugars, 14% phosphate, 35% carbazol-positive compounds, and 11% fatty acids (containing iso- and anteiso-fatty acyl chains). Rare for outer membrane lipids, OML contains no significant amount of 3-deoxy-D-manno-octulosonic acids, heptoses, and beta-hydroxy fatty acids. The fatty acyl chain composition, being similar to that of the cytoplasmic membrane, is quite heterogeneous with anteiso-pentadecanoic acid (12%), palmitic acid (51%), and iso-palmitic acid (19%) as the predominant fatty acids present. Findings of a glycerol-hexose unit and two glycerol-hexadecanoic acid fragments indicate a glycolipid membrane anchor typically found in LTA. There was also no evidence for the presence of a sphingosine-based lipid structure. The results of FTIR measurements strongly suggest that the reconstituted lipid forms normal bilayer structures (vesicles) expressing a high membrane state of order with a distinct phase transition as typical for isolated LPS. However, in contrast to LPS, OML of T. denticola has a lower Tm near 22 degreesC and a lower cooperativity of the phase transition. The results suggest a different kind of permeation barrier that is built up by this particular OML of T. denticola, which is quite different from LPS normally essential for Gram-negative bacteria.

The periodontal-orthodontic interface: a simple solution to a difficult problem

A technique which combines the use of a sectional fixed and removable appliance in periodontally compromised dentitions is described. The rationale behind treatment in these patients is discussed and the relative advantages over other techniques highlighted.

Cytopathic effects of the major surface protein and the chymotrypsinlike protease of Treponema denticola

Prominent antigens of Treponema denticola have been suggested to be mediators of the cytopathic effects typically seen in periodontal disease. In the present study of the T. denticola major surface protein (Msp) and the surface-expressed chymotrypsinlike protease complex (CTLP), we characterized the ability of these proteins to adhere to and lyse epithelial cells. Msp and CTLP were closely associated in spirochete outer membranes. Purified Msp, both native and recombinant, and CTLP bound to glutaraldehyde-fixed periodontal ligament epithelial cells. Adherence of Msp was partially blocked by specific antibodies. Adherence of CTLP was partially blocked by serine protease inhibitors and was further inhibited by specific antibodies. Both native Msp and CTLP were cytotoxic toward periodontal ligament epithelial cells, and their cytotoxicity was inhibited by the same treatments that inhibited adherence. Msp, but not CTLP, lysed erythrocytes. Msp complex (partially purified outer membranes free of protease activity) was cytotoxic toward a variety of different cell types. Pore-forming activities of recombinant Msp in black lipid model membrane assays and in HeLa cell membranes were similar to those reported for the native protein, supporting the hypothesis that Msp cytotoxicity was due to its pore-forming activity.

Molecular epidemiology of oral treponemes associated with periodontal disease

Periodontitis, a disease responsible for tooth loss worldwide, is characterized by chronic inflammation of the periodontium, eventually leading to destruction of periodontal ligaments and supporting alveolar bone. Spirochetes, identified by dark-field microscopy as being the most predominant bacteria in advanced lesions, are thought to play a causative role. Various spirochetal morphotypes were observed, but most of these morphotypes are as yet uncultivable. To assess the role of these organisms we designed oligonucleotide probes for the identification of both cultivable and so far uncultivable spirochetes in periodontitis patients. Subgingival plaque specimens taken from diseased sites (n = 200) and healthy control sites (n = 44) from 53 patients with rapidly progressive periodontitis (RPP) were submitted to direct in situ hybridization or dot blot hybridization after prior amplification with eubacterial primers. Spirochetes were found in all patients, but their distributions varied considerably. Parallel use of oligonucleotide probes specific for cultivable or so far uncultivable treponemes suggested the presence of novel yet unknown organisms at a high frequency. These uncultivable treponemes were visualized by fluorescence in situ hybridization, and their morphologies, sizes, and numbers could be estimated. All RPP patients included in this study harbored oral treponemes that represent either novel species, e.g., Treponema maltophilum, or uncultivable phylotypes. Therefore, it is necessary to include these organisms in etiologic considerations and to strengthen efforts to cultivate these as yet uncultivable treponemes.

Association of oral spirochetes from sites of periodontal health with development of periodontitis

The purpose of this investigation was to determine whether the presence of disease-associated bacteria in health-associated plaque correlated with susceptibility to periodontitis over time. Sites of periodontal health were identified in 65 adults. Six months later (recall 1), plaque was collected from sites that remained in periodontal health, and specific bacteria were detected using monoclonal antibodies in a microscopic assay. The spirochete morphogroup was identified by phase contrast microscopy. The relationship between detection at recall 1 and development of periodontitis over two successive 6-month intervals (recalls 2 and 3) was evaluated by means of logistic regression using generalized estimating equations (GEE), from which odds ratios (OR) were estimated and tested for significance. Significant relationships were defined as those having ORs with P < 0.05. Ninety-three of 1,032 sites developed signs of early periodontitis over the 12-month interval between recall 1 and recall 3. The spirochete morphogroup (OR = 3.13, P < 0.001) and pathogen-related oral spirochetes (PROS) (OR = 3.68, P < 0.001) were significantly associated with healthy sites that developed periodontitis. The association of Treponema socranskii was not significant (OR = 3.62, P = 0.0918). Odds ratios for Campylobacter rectus, Eikenella corrodens, and Porphyromonas gingivalis were less than 2.0 and not significant. Treponema denticola was not detected in health-associated plaque from stable health sites and was detected in only three sites that progressed to periodontitis. These findings indicate that the presence of PROS and some unidentified spirochetes in health-associated plaque is associated with increased susceptibility to periodontitis.

Differential attachment of oral treponemes to monolayers of epithelial cells

This in vitro study describes the attachment properties of several oral treponemes to monolayers of epithelial cells and the effect of epithelial cell confluence on treponeme attachment. Four serotypes of Treponema denticola, Treponema scoliodontum, three subspecies of Treponema socranskii, and Treponema vincentii were tested with monolayers of epithelial cells of human and canine origin. Attachment of oral treponemes were compared to attachment by T. pallidum subsp. pallidum, and by the non-pathogen Treponema phagedenis. Results indicated that different serotypes of T. denticola had similar abilities to attach to epithelial cells. However, subspecies of T. socranskii differed in their ability to attach to epithelial cells. The proportion of epithelial cells susceptible to attachment by oral spirochetes was strongly related to the confluence level of the monolayer. In contrast, T. pallidum attached equally well to both epithelial cell lines at all confluence levels. T. phagedenis attached to < 1% of all epithelial cells. In general, attachment of oral treponemes to canine cells was lower than to human cells, suggesting species-specificity for adherence. Attachment of oral treponemes to epithelial cells may promote colonization of the periodontal pocket, as well as retention of treponeme colonies within plaque. The preference of oral treponemes to attach to cells of low confluence fields may translate in vivo to an increased ability to attach to cells which are actively dividing. Such cells are found in areas of repair, a common status within inflamed periodontal pockets. Furthermore, attachment of oral treponemes to epithelial cell barriers may promote or potentiate cytopathic processes.

Identification, isolation, and characterization of the 42-kilodalton major outer membrane protein (MompA) from Treponema pectinovorum ATCC 33768

The major protein present in the isolated outer membrane of Treponema pectinovorum ATCC 33768, MompA, was identified, purified, and characterized. Immuno-gold electron microscopy, using anti-MompA serum, and cell fractionation experiments confirmed the localization of MompA to the outer membrane. MompA was determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis to have a molecular mass of 42 kDa when heat denatured, whereas native MompA formed a number of detergent-stable forms with molecular masses of 71, 76, and 83 kDa. A temperature of 60 degrees C was required to convert the native protein to the 42-kDa form. A number of detergents and chemical agents that are capable of breaking ionic and hydrogen bonds of proteins did not convert native MompA to the 42-kDa species. The native forms of the protein were resistant to the combined action of proteinase K, trypsin, and chymotrypsin, whereas the 42-kDa form of MompA was not. The N-terminal amino acid sequence of MompA was determined to be DVTVNINSRVRPVLYTT, and database searches did not identify any homology with known protein sequences. Amino acid compositional analysis showed the protein to be rich in proline and glycine, with these amino acids accounting for 28 and 13%, respectively, of the total amino acids. Antiserum raised against the major outer membrane protein of T. denticola GM-1 and ATCC 35405 did not cross-react with MompA, and antiserum raised against MompA did not react with any cellular components of Treponema denticola, Treponema vincentii, or Treponema socranskii. A major outer membrane protein similar in molecular mass to MompA was identified in eight clinical isolates of T. pectinovorum. The major outer membrane protein produced by four of the clinical isolates reacted strongly, by Western blotting, with anti-MompA serum, whereas proteins of the other strains did not.

Release and activation of human neutrophil matrix metallo- and serine proteinases during phagocytosis of Fusobacterium nucleatum, Porphyromonas gingivalis and Treponema denticola

The phagocytic ingestion of reference strains and clinical isolates of Fusobacterium nucleatum, Porphyromonas gingivalis, and Treponema denticola by polymorphonuclear leukocytes (PMNs) and the concomitant release of PMN granule proteinases were studied by specific functional and immunological assays. PMNs were incubated with the microorganisms anaerobically at 37 degrees C for indicated time periods. The suspensions and pellets were used for phagocytic ingestion assay and electron microscopic study, respectively. The supernatants were used for the measurements of the amounts and activities of the released PMN enzymes including PMN gelatinase (MMP-9), collagenase (MMP-8), serine proteases (elastase and cathepsin G), and lactate dehydrogenase (LDH). Both fluorescence microscopy and transmission electron microscopy showed that F. nucleatum, P. gingivalis and T. denticola were ingested by the PMNs in comparable numbers. However, measurements of the enzymes released from the triggered PMNs revealed major differences among the three species. High amount of elastase was released from the PMNs triggered by F. nucleatum, but not by P. gingivalis or T. denticola. The treatment of PMNs with P. gingivalis whole cells resulted in the release of gelatinase partly in the 82 kD active form, suggesting proteolytic activation of the degranulated 92 kD proMMP-9. The 82 kD active form of gelatinase was not detected upon triggering the PMNs with F. nucleatum and T. denticola. The PMN-bacteria interaction did not result in release of LDH from triggered PMNs indicating the proteinase release was not due to the PMN cell death. The results show that the susceptibilities of the 3 potentially periodontopathogenic microorganisms, F. nucleatum, P. gingivalis and T. denticola to phagocytic ingestion are not directly related to the amounts and activities of PMN enzymes released during the bacteria-PMN interactions. As PMN degranulation is considered as one of the major pathogenic mechanisms in periodontitis, the observed differences among the microorganisms may be important virulence characteristics of these species.

Risk assessment for periodontal diseases

Assessment of risk for periodontitis is still in its infancy. Nevertheless, a sufficient amount of dependable information exists to begin using risk assessment in the day to day practice of dentistry. The purpose of this paper is to summarise existing information about risks for periodontitis in a manner that is useful to practitioners. Risks for moderate to severe periodontitis that have been identified include cigarette smoking, advancing age, diabetes mellitus and certain other systemic conditions. These include, osteoporosis and HIV infection and conditions such as irradiation and immunosuppressive drugs that interfere with normal host defences, specific pathogenic bacteria in the subgingival flora, microbial deposits and poor oral hygiene status, bleeding on probing, previous disease experience and severity, and inheritance. Some risks such as pathogenic bacteria in the subgingival flora are strongly linked to causation of the disease while others such as bleeding on probing may indicate enhanced risk for future disease but are not known to be involved in causation and still others such as advancing age may be background factors that enhance susceptibility. While some risks such as cigarette smoking can be modified to lower the level of risk, others such as ageing are immutable and cannot be modified but need to be considered in overall risk assessment. A goal of periodontal diagnosis, treatment planning and therapy is to lower risk for future periodontal deterioration to the maximal extent. One approach to achieving this goal is described.

Principles of evaluation of the diagnostic value of subgingival bacteria

This paper describes steps in the process of evaluating subgingival bacteria assays for the diagnosis of periodontal disease. The first step examines the infectious etiology of periodontal disease in pointing to specific oral bacteria as periodontal pathogens. Second is characterization of the laboratory test to detect and quantitate these pathogens as to sensitivity, specificity, and positive and negative predictive value. Third is the role of the laboratory test in the diagnosis of the different forms of periodontal disease which is related to the current clinical rather than microbiological definition of these diseases. The fourth and most important step is an analysis of the significance of subgingival bacterial tests in clinical decision-making.

Conservation of msp, the gene encoding the major outer membrane protein of oral Treponema spp

The major surface protein (Msp) of Treponema denticola has been implicated as a mediator of the interaction between the spirochete and the gingival epithelium in periodontal diseases. Previous studies showed that the Msp of T. denticola ATCC 35405 had porin activity, depolarized epithelial cell membranes, bound to extracellular matrix components of epithelial cells, and formed a regular hexagonal surface array in the treponemal outer membrane. The gene encoding Msp in ATCC 35405 was recently cloned, sequenced, and expressed in Escherichia coli (J. C. Fenno, K.-H. Müller, and B. C. McBride, J. Bacteriol. 178:2489-2496, 1996). In the present study, we identified genes encoding Msp-like proteins in several oral spirochetes. A prominent heat-modifiable Msp-like protein having an apparent molecular mass of between 43 and 64 kDa was present in all oral spirochete strains tested. Antibodies raised against the ATCC 35405 Msp reacted strongly with the Msp proteins of T. denticola ATCC 35404 and T. vincentii, reacted very weakly with the Msp protein of T. denticola ATCC 33520, and did not react with T. denticola OTK, T. socranskii, and T. pectinovorum. The msp loci of the T. denticola strains and T. vincentii were identified in analyses using PCR with oligonucleotide primers derived from the DNA sequence flanking msp in ATCC 35405. Southern blot analysis showed at least three groups of related msp DNA sequences. Comparison of DNA sequences of the 5' and 3' ends of the msp genes showed high sequence homology in the flanking regions and signal peptide coding regions, while the homologies between regions encoding the mature peptide were as low as 50%. The entire msp DNA sequences of T. denticola ATCC 33520 and OTK were determined, and the deduced Msp amino acid sequences were compared to the sequence of the previously reported Msp of ATCC 35405. The results show that the msp locus is conserved in oral treponemes but that there are significant differences between the mature Msp peptides of different strains. Further studies of the antigenic domains, functional domains, and physical structures of Msp proteins, based on these results, will enhance understanding of the role of Msp in the cytopathology associated with oral spirochetes.

Characterization of the Treponema denticola prtP gene encoding a prolyl-phenylalanine-specific protease (dentilisin)

A chymotrypsin-like protease from Treponema denticola ATCC 35405 was purified by chromatographic techniques. The purified enzyme consisted of three polypeptides (38, 43, and 72 kDa). The protease exhibited specificity for peptide bonds containing phenylalanine and proline at the P1 and P2 positions, respectively, and was classified as a serine protease on the basis of inhibition studies. Naturally occurring protease inhibitors such as alpha1-antitrypsin and alpha1-antichymotrypsin had no effect on enzymatic activity. The enzyme degraded fibronectin, alpha1-antitrypsin, and gelatin while weakly degrading the immunoglobulin G heavy chain and type IV collagen. N-terminal amino acid sequences were determined for the 43- and 72-kDa proteins. On the basis of these sequences, the genes coding for the 43- and 72-kDa proteins were isolated and sequenced. The open reading frame which codes for the 72-kDa protein was designated prtP. This gene consists of 2,169 bp and codes for a protein with an Mr of 77,471. The protein appeared to be composed of a signal peptide region followed by a prosequence and the mature protein domain. The deduced amino acid sequence exhibited similarity with that of the Bacillus subtilis serine protease subtilisin. The deduced properties of the sequence suggest that the 72-kDa protein is a chymotrypsin-like protease. However, the nature and function of the 43-kDa protein have not yet been determined.