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Wirth R, Pap B, Maróti G, Vályi P, Komlósi L, Barta N, Strang O, Minárovits J, Kovács KL. Toward Personalized Oral Diagnosis: Distinct Microbiome Clusters in Periodontitis Biofilms. Front Cell Infect Microbiol 2022; 11:747814. [PMID: 35004342 PMCID: PMC8727345 DOI: 10.3389/fcimb.2021.747814] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/29/2021] [Indexed: 12/21/2022] Open
Abstract
Periodontitis is caused by pathogenic subgingival microbial biofilm development and dysbiotic interactions between host and hosted microbes. A thorough characterization of the subgingival biofilms by deep amplicon sequencing of 121 individual periodontitis pockets of nine patients and whole metagenomic analysis of the saliva microbial community of the same subjects were carried out. Two biofilm sampling methods yielded similar microbial compositions. Taxonomic mapping of all biofilms revealed three distinct microbial clusters. Two clinical diagnostic parameters, probing pocket depth (PPD) and clinical attachment level (CAL), correlated with the cluster mapping. The dysbiotic microbiomes were less diverse than the apparently healthy ones of the same subjects. The most abundant periodontal pathogens were also present in the saliva, although in different representations. The single abundant species Tannerella forsythia was found in the diseased pockets in about 16–17-fold in excess relative to the clinically healthy sulcus, making it suitable as an indicator of periodontitis biofilms. The discrete microbial communities indicate strong selection by the host immune system and allow the design of targeted antibiotic treatment selective against the main periodontal pathogen(s) in the individual patients.
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Affiliation(s)
- Roland Wirth
- Department of Biotechnology, University of Szeged, Szeged, Hungary
| | - Bernadett Pap
- Biological Research Center, Institute of Plant Biology, Szeged, Hungary
| | - Gergely Maróti
- Biological Research Center, Institute of Plant Biology, Szeged, Hungary
| | - Péter Vályi
- Department of Periodontology, University of Szeged, Szeged, Hungary
| | - Laura Komlósi
- Department of Oral Surgery, University of Szeged, Szeged, Hungary
| | - Nikolett Barta
- Department of Biotechnology, University of Szeged, Szeged, Hungary
| | - Orsolya Strang
- Department of Biotechnology, University of Szeged, Szeged, Hungary.,Department of Oral Biology and Experimental Dental Research, University of Szeged, Szeged, Hungary
| | - János Minárovits
- Department of Oral Biology and Experimental Dental Research, University of Szeged, Szeged, Hungary
| | - Kornél L Kovács
- Department of Biotechnology, University of Szeged, Szeged, Hungary.,Department of Oral Biology and Experimental Dental Research, University of Szeged, Szeged, Hungary
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Söderlin MK, Persson GR, Renvert S, Sanmartin Berglund J. Cytokines in gingival crevicular fluid in elderly rheumatoid arthritis patients in a population-based cross-sectional study: RANTES was associated with periodontitis. J Periodontal Res 2021; 56:907-916. [PMID: 33954982 PMCID: PMC8518573 DOI: 10.1111/jre.12887] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/09/2021] [Accepted: 04/10/2021] [Indexed: 12/13/2022]
Abstract
Objective We studied cytokines in gingival crevicular fluid (GCF) in a cross‐sectional population‐based cohort of rheumatoid arthritis (RA) patients ≥61 years of age with and without a diagnosis of periodontitis. Background data Earlier studies on cytokines in GCF in RA patients have not given clear results. Methods In a population‐based cross‐sectional study of patients ≥61 years of age, 233 RA patients were identified. 132 (57%) dentate RA patients participated. All participants received rheumatological and dental examinations, and had a panoramic radiograph taken. GCF was sampled on each patient. Interleukins 1‐β (IL‐1β), IL‐4, IL‐6, IL‐10, IL‐17A, tumor necrosis factor alpha (TNF‐α), interferon gamma (IFN‐γ), and chemokines RANTES/CCL5, eotaxin and monocyte chemoattractant protein (MCP‐1) were analyzed in GCF. These cytokines were stratified for periodontitis, age, gender, body mass index (BMI), smoking, and anti‐cyclic citrullinated protein (anti‐CCP) status. Binary logistic regression analyses with periodontitis as outcome were performed adjusting for the above mentioned confounding factors including anti‐rheumatic medication, disease duration and the cytokine in question. Results Periodontitis was diagnosed in 80/132 (61%) of study participants. The 110 RA patients not participating were older, had a higher mean erythrocyte sedimentation rate (ESR), had a higher mean DAS28ESR (Disease Activity Score 28 using ESR) and were less often on biologic treatment. Only RANTES was associated with periodontitis (p = .049, OR 1.001, 95% CI 1.000–1.002) in the binary logistic regression analyses. Conclusion In this population‐based elderly RA cohort, neither pro‐inflammatory nor anti‐inflammatory cytokines in GCF were clearly associated with a diagnosis of periodontitis.
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Affiliation(s)
- Maria K Söderlin
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Gösta Rutger Persson
- Department of Periodontics, and the Department of Oral Medicine, University of Washington, Seattle, WA, USA
| | - Stefan Renvert
- Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden.,Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden.,School of Dental Science, Trinity College, Dublin, Ireland.,Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
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Ikeda E, Shiba T, Ikeda Y, Suda W, Nakasato A, Takeuchi Y, Azuma M, Hattori M, Izumi Y. Deep sequencing reveals specific bacterial signatures in the subgingival microbiota of healthy subjects. Clin Oral Investig 2019; 23:1489-1493. [PMID: 30680442 DOI: 10.1007/s00784-019-02805-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 01/11/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This study aimed to define the comprehensive bacterial flora of the healthy oral cavity by identifying and comparing bacterial species in different subgingival sites using 454 sequencing of 16S rRNA genes. MATERIALS AND METHODS Subgingival plaque samples were taken from six target teeth (central incisor, first premolar, and first molar in both the maxilla and mandible) of 10 periodontally healthy patients. Bacterial DNA was extracted and next-generation sequencing of 16S rRNA genes was performed. RESULTS Bacterial composition in phylum level was similar for all sites within the same individual irrespective of tooth location. Unweighted UniFrac distance values of microbiome also showed that average distance was significantly larger between subjects than between tooth locations of the same subjects. CONCLUSIONS The present results clarify the lack of effect of tooth location in the healthy subgingival microbiota. Results may suggest that any subgingival site can demonstrate similar subject-specific microbiota. CLINICAL RELEVANCE This investigation offers a better understanding of the uniqueness of the oral microbiome. The present study will facilitate sampling in future subgingival microbiological studies.
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Affiliation(s)
- Eri Ikeda
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takahiko Shiba
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Ikeda
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Wataru Suda
- RIKEN Center for Integrative Medical Sciences, Yokohama, Japan.,Department of Microbiology and Immunology, Keio University School of Medicine, Tokyo, Japan
| | - Akinori Nakasato
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuo Takeuchi
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Miyuki Azuma
- Department of Molecular Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masahira Hattori
- RIKEN Center for Integrative Medical Sciences, Yokohama, Japan.,Faculty of Science and Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Yuichi Izumi
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Microbiological analysis and the outcomes of periodontal treatment with or without adjunctive systemic antibiotics—a retrospective study. Clin Oral Investig 2018; 22:3031-3041. [DOI: 10.1007/s00784-018-2392-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 02/14/2018] [Indexed: 02/06/2023]
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Fontana CR, Grecco C, Bagnato VS, de Freitas LM, Boussios CI, Soukos NS. Molecular analyses of two bacterial sampling methods in ligature-induced periodontitis in rats. Clin Exp Dent Res 2018; 4:19-24. [PMID: 29744211 PMCID: PMC5813890 DOI: 10.1002/cre2.98] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 11/10/2017] [Accepted: 11/20/2017] [Indexed: 01/23/2023] Open
Abstract
The prevalence profile of periodontal pathogens in dental plaque can vary as a function of the detection method; however, the sampling technique may also play a role in determining dental plaque microbial profiles. We sought to determine the bacterial composition comparing two sampling methods, one well stablished and a new one proposed here. In this study, a ligature-induced periodontitis model was used in 30 rats. Twenty-seven days later, ligatures were removed and microbiological samples were obtained directly from the ligatures as well as from the periodontal pockets using absorbent paper points. Microbial analysis was performed using DNA probes to a panel of 40 periodontal species in the checkerboard assay. The bacterial composition patterns were similar for both sampling methods. However, detection levels for all species were markedly higher for ligatures compared with paper points. Ligature samples provided more bacterial counts than paper points, suggesting that the technique for induction of periodontitis could also be applied for sampling in rats. Our findings may be helpful in designing studies of induced periodontal disease-associated microbiota.
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Affiliation(s)
- Carla Raquel Fontana
- Universidade Estadual Paulista (Unesp), Faculdade de Ciências FarmacêuticasAraraquaraSPBrazil
| | - Clovis Grecco
- Instituto de Física‐Grupo de Óptica–Universidade de Sao Paulo, USPSPBrazil
| | | | - Laura Marise de Freitas
- Universidade Estadual Paulista (Unesp), Faculdade de Ciências FarmacêuticasAraraquaraSPBrazil
| | - Constantinos I. Boussios
- Laboratory for Information and Decision SystemsMassachusetts Institute of Technology, MITMassachusettsUSA
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El Kossi MM, Darwish SF, Agwuh K, Milupi M. Peritoneal dialysis exit-site leak complicated by peritoneal dialysis-related peritonitis due to Actinomyces neuii. JMM Case Rep 2015. [DOI: 10.1099/jmmcr.0.000096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Hallström H, Persson GR, Strömberg U, Twetman S, Renvert S. Reproducibility of subgingival bacterial samples from patients with peri-implant mucositis. Clin Oral Investig 2014; 19:1063-8. [PMID: 25261401 DOI: 10.1007/s00784-014-1324-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 09/15/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The aim of the present study was to investigate the reproducibility of bacterial enumeration from subsequent subgingival samples collected from patients with peri-implant mucositis. MATERIAL AND METHODS Duplicate microbial samples from 222 unique implant sites in 45 adult subjects were collected with paper points and analyzed using the checkerboard DNA-DNA hybridization technique. Whole genomic probes of 74 preselected bacterial species were used. Based on the bacterial scores, Cohen's kappa coefficient was used to calculate the inter-annotator agreement for categorical data. The percentage agreement was considered as "good" when the two samples showed the same score or differed by 1 to the power of 10. RESULTS Moderate to fair kappa values were displayed for all bacterial species in the test panel (range 0.21-0.58). There were no significant differences between Gram-positive and Gram-negative species. The percentage of good agreement between the first and second samples averaged 74.7 % (n = 74; range 56-83 %), while the proportion of poor agreement ranged from 1 to 19 % for the various strains. CONCLUSION While an acceptable clinical agreement was obtained in most cases, diverging bacterial scores may appear in subgingival samples collected at the same time point from patients with peri-implant mucositis. CLINICAL RELEVANCE The broad bulky base of implant crowns may present an obstacle for the collection of reproducible subgingival samples with paper points.
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Affiliation(s)
- Hadar Hallström
- Department of Periodontology, Faculty of Odontology, Malmö University, SE-20506, Malmö, Sweden,
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Mäntylä P, Buhlin K, Paju S, Persson GR, Nieminen MS, Sinisalo J, Pussinen PJ. Subgingival Aggregatibacter actinomycetemcomitans associates with the risk of coronary artery disease. J Clin Periodontol 2013; 40:583-90. [PMID: 23521427 DOI: 10.1111/jcpe.12098] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2013] [Indexed: 12/22/2022]
Abstract
AIM We investigated the association between angiographically verified coronary artery disease (CAD) and subgingival Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia and Treponema denticola. MATERIALS AND METHODS The cross-sectional study population (n = 445) comprised 171 (38.4%) patients with Stable CAD, 158 (35.5%) with acute coronary syndrome (ACS) and 116 (26.1%) with no significant CAD (No CAD). All patients participated in clinical and radiological oral health examinations. Pooled subgingival bacterial samples were analysed by checkerboard DNA-DNA hybridization assays. RESULTS In all study groups, the presence of P. gingivalis, T. forsythia and T. denticola indicated a significant (p ≤ 0.001) linear association with the extent of alveolar bone loss (ABL), but A. actinomycetemcomitans did not (p = 0.074). With a threshold level of bacterial cells 1 × 10(5) A. actinomycetemcomitans was significantly more prevalent in the Stable CAD group (42.1%) compared to the No CAD group (30.2%) (p = 0.040). In a multi-adjusted logistic regression analysis using this threshold, A. actinomycetemcomitans positivity associated with Stable CAD (OR 1.83, 95% CI 1.00-3.35, p = 0.049), but its level or levels of other bacteria did not. CONCLUSIONS The presence of subgingival A. actinomycetemcomitans associates with an almost twofold risk of Stable CAD independently of alveolar bone loss.
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Affiliation(s)
- Päivi Mäntylä
- Institute of Dentistry, University of Helsinki, Helsinki, Finland
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Abstract
OBJECTIVE To analyze the subgingival microflora composition of inflammatory bowel disease (IBD) patients with untreated chronic periodontitis and compare them with systemically healthy controls also having untreated chronic periodontitis. METHOD Thirty IBD patients [15 with Crohn's disease (CD) and 15 with ulcerative colitis (UC)] and 15 control individuals participated in the study. All patients had been diagnosed with untreated chronic periodontitis. From every patient, subgingival plaque was collected from four gingivitis and four periodontitis sites with paper points. Samples from the same category (gingivitis or periodontitis) in each patient were pooled together and stored at -70 °C until analysis using a checkerboard DNA-DNA hybridization technique for 74 bacterial species. RESULTS Multiple-comparison analysis showed that the groups differed in bacterial counts for Bacteroides ureolyticus, Campylobacter gracilis, Parvimonas micra, Prevotella melaninogenica, Peptostreptococcus anaerobius, Staphylococcus aureus, Streptococcus anginosus, Streptococcus intermedius, Streptococcus mitis, Streptococcus mutans, and Treponema denticola (P<0.001). CD patients had significantly higher levels of these bacteria than UC patients either in gingivitis or in periodontitis sites (P<0.05). CD patients harbored higher levels of P. melaninogenica, S. aureus, S. anginosus, and S. mutans compared with controls both at gingivitis and at periodontitis sites (P<0.05). UC patients harbored higher levels of S. aureus (P=0.01) and P. anaerobius (P=0.05) than controls only in gingivitis sites. CONCLUSION Our study showed that even with similar clinical periodontal parameters, IBD patients harbor higher levels of bacteria that are related to opportunistic infections in inflamed subgingival sites that might be harmful for the crucial microbe-host interaction.
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Lauenstein M, Kaufmann M, Persson GR. Clinical and microbiological results following nonsurgical periodontal therapy with or without local administration of piperacillin/tazobactam. Clin Oral Investig 2013; 17:1645-60. [DOI: 10.1007/s00784-012-0856-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 09/27/2012] [Indexed: 10/27/2022]
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Nguyen-Hieu T. Microbial sampling process can change results of microbiological analysis in periodontitis diagnosis. A minireview. ACTA ACUST UNITED AC 2012. [PMID: 23188761 DOI: 10.1111/jicd.12010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This minireview aims to verify the supposition that the microbial sampling process can change results of microbiological analysis in periodontitis diagnosis. The literature search via Pubmed yielded 52 appropriate articles for analysis. Of which 38% (20/52) described that the sampling sites were isolated from saliva, whereas 62% (32/52) did not. Also, 29% (15/52) declared that the microbial sampling was performed before probing pocket depth (PPD), whereas 71% (37/52) did not. Comparison of the results of microbiological analysis in these studies showed that the bacteria most frequently detected in periodontal pockets was variable. Therefore, a sampling process that includes both the microbial sample being taken before PPD and saliva isolation of the sampling sites is needed to ensure the accuracy of microbiological analysis in periodontitis diagnosis.
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Affiliation(s)
- Tung Nguyen-Hieu
- Aix-Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, Marseille, France.
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Bieri RA, Adriaens L, Spörri S, Lang NP, Persson GR. Gingival fluid cytokine expression and subgingival bacterial counts during pregnancy and postpartum: a case series. Clin Oral Investig 2012; 17:19-28. [DOI: 10.1007/s00784-012-0674-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 01/04/2012] [Indexed: 11/28/2022]
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Zeigler CC, Persson GR, Wondimu B, Marcus C, Sobko T, Modéer T. Microbiota in the oral subgingival biofilm is associated with obesity in adolescence. Obesity (Silver Spring) 2012; 20:157-64. [PMID: 21996660 DOI: 10.1038/oby.2011.305] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
To test the hypothesis whether microbiota in oral biofilm is linked with obesity in adolescents we designed this cross-sectional study. Obese adolescents (n = 29) with a mean age of 14.7 years and normal weight subjects (n = 58) matched by age and gender were examined with respect to visible plaque index (VPI%) and gingival inflammation (bleeding on probing (BOP%)). Stimulated saliva was collected. They answered a questionnaire concerning medical history, medication, oral hygiene habits, smoking habits, and sociodemographic background. Microbiological samples taken from the gingival crevice was analyzed by checkerboard DNA-DNA hybridization technique. The sum of bacterial cells in subgingival biofilm was significantly associated with obesity (P < 0.001). The link between sum of bacterial cells and obesity was not confounded by any of the studied variables (chronic disease, medication, VPI%, BOP%, flow rate of whole saliva, or meal frequency). Totally 23 bacterial species were present in approximately threefold higher amounts, on average, in obese subjects compared with normal weight controls. Of the Proteobacteria phylum, Campylobacter rectus and Neisseria mucosa were present in sixfold higher amounts among obese subjects. The association between obesity and sum of bacterial cells in oral subgingival biofilm indicates a possible link between oral microbiota and obesity in adolescents.
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Affiliation(s)
- Cecilia C Zeigler
- Division of Pediatric Dentistry, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Tongue piercing: the effect of material on microbiological findings. J Adolesc Health 2011; 49:76-83. [PMID: 21700161 DOI: 10.1016/j.jadohealth.2010.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 10/12/2010] [Accepted: 10/21/2010] [Indexed: 11/23/2022]
Abstract
PURPOSE Biofilms on oral piercings may serve as a bacterial reservoir and lead to systemic bacteremia or local transmission of pathogenic microbiota. The use of piercing materials which are less susceptible to biofilm accumulation could contribute to prevention of problems. The present study investigated whether there are microbiological differences in bacterial samples collected from tongue piercings made of different materials. METHODS A total of 85 subjects with tongue piercings participated in this study. After a baseline dental examination, sterile piercings of four different materials were randomly allocated to the study subjects. After 2 weeks, microbiologic samples were collected and processed by checkerboard deoxyribonucleic acid- deoxyribonucleic acid hybridization methods. RESULTS About 28.8% of subjects reported 61 lingual recessions (1.91 ± .96 mm), whereas 5% reported tooth chipping on one tooth each. With the exception of Aggregatibacter actinomycetemcomitans (Y4), Fusobacterium nucleatum species, and Parvimonas micra, bacteria associated with periodontitis were not commonly found in the samples from studs or piercing channels. Of the 80 bacterial species, 67 were found at significantly higher levels (p < .001) in samples from stainless steel than from polytetrafluoroethylene or polypropylene piercings. CONCLUSION The low bacterial counts from piercing channels suggest that having a tongue pierced would not contribute to an increased risk for oral infection. The present study demonstrated that studs made of steel might promote the development of a biofilm, whereas those made of polytetrafluoroethylene or polypropylene may be rather inert to bacterial colonization. The finding of Staphylococci on steel and titanium studs may suggest an elevated risk for complication if the piercing channel is infected.
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Duss C, Lang NP, Cosyn J, Persson GR. A randomized, controlled clinical trial on the clinical, microbiological, and staining effects of a novel 0.05% chlorhexidine/herbal extract and a 0.1% chlorhexidine mouthrinse adjunct to periodontal surgery. J Clin Periodontol 2010; 37:988-97. [DOI: 10.1111/j.1600-051x.2010.01609.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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