Microbiology

Periodontal Disease:
University of Puerto Rico - Medical Science Campus
Periodontics Program
Dra. Yollian Velázquez González PYG-1
Educational objectives

➢ Oral microbiome and ecological niches

➢ Periodontal tissues
➢ Gingival Plaque
➢ Socransky complex
➢ Bacterias
➢ Experimental gingivitis
➢ Plaque Theories
➢ Acquired Pellicle
➢ Bacterial Colonization
➢ Dysbiosis
➢ Etiology
The entire human microbial flora is formed by a complex collection of approximately
10^14 microorganisms (Sender et al. 2016).

For millions of years, our resident microbes have coevolved and coexisted
with us in a mostly harmonious symbiotic relationship.
The oral cavity is home to approximately 700
species of bacteria that together comprise the oral
microbiome.
(Deo and Deshmukh, 2019)

Ranking second in terms of species:

diversity and complexity only to the

gastrointestinal microbiota.

He, J.; Li, Y.; Cao, Y.; Xue, J.; Zhou, X. The oral microbiome diversity and its
relation to human diseases. Folia Microbiol. 2015, 60, 69–80
The oral microbiome
is composed of a diverse ecosystem of
microbial organisms that

➢ metabolically and physically interact.

(Rosan and Lamont, 2000; Kim et al., 2020)

 In the state of oral health, there is homeostasis
in the bacterial ecosystem and it provides a dynamic
balance with mutual benefits for the host and
microorganisms.
 Periodontal
Ligament
The periodontal tissue
forms the supporting structure
of the teeth that includes:

➢ Gingiva
Gingiva ➢ Alveolar Bone
➢ Cementum
➢ Periodontal ligament
Alveolar Bone

Cementum
Dental plaque

Bacterias

Inflammation Calculus
G ingival Plaque
Dental plaque is a biofilm composed of a
complex microbial community, food
particle (carbohydrates) and saliva.

Supragingival plaque is located coronally

or above the gingival margin.

Subgingival plaque is located apically or

below the gingival margin in the gingival
sulcus or periodontal pocket.
Bacterias
Supragingival samples exhibited significantly higher counts of Streptococcus species, Actinomyces
naeslundii genospecies, Actinomyces israelii, Actinomyces odontolyticus, Neisseria mucosa, Streptococcus
gordonii, Capnocytophaga ochracea and Capnocytophaga sputigena when compared with mean
counts in subgingival samples taken from the same tooth surfaces.

Subgingival plaque samples presented significantly higher counts of Prevotella nigrescens, Prevotella
intermedia, Bacteroides forsythus and Porphyromonas gingivalis.
Socransky 1998
In 1998, Dr. Sigmund Socransky developed the “complex
theory” where periodontal pathogens are categorized based
on their association with the severity of disease.

In the complex theory, periodontal pathogens have been

classified by color to indicate which bacteria are associated
with the onset and progression of periodontal disease.

The classification includes the red complex, orange

complex, green complex, yellow complex, and Aa
complex.
Streptococcus gordonii
Gram-positive bacterium included
among some of the initial colonizers of the
periodontal environment.

Has a high affinity for molecules in the

salivary pellicle on tooth surfaces, therefore
can rapidly colonize clean tooth surfaces,
and

S. gordonii along with related

organisms comprise a high percentage, up to
70%, of the bacterial biofilm that forms on
clean tooth surfaces.
 Veillonella parvula
Gram-negative commensal microorganism

Causing agent for dental caries and periodontitis.

It acts as opportunistic pathogen upon suitable growth

conditions for the bacterium.

V.parvula, an important colonizer of dental plaque,

promotes multispecies growth and plays prime role in lactic
acid fermentation.
Fusobacterium nucleatum

Gram-negative rods, anaerobic obligate

Act as a physical interaction between gram-positive and

gram-negative bacteria, which is a bridge between
symbiotes and true pathogens (Kolenbrander, 2000).

Adhesins which are found on the surface can attach to

other bacteria

It can invade different host cells, such as epithelial cells,

endothelial cells, and fibroblasts .
Aggregatibacter actinomycetemcomitans

Aggregatibacter actinomycetemcomitans is a
Gram-negative, facultative anaerobe, nonmotile
bacterium that is often found in association with localized
aggressive periodontitis.

It is one of the bacteria that might be implicated in

destructive periodontal disease.

It possesses certain virulence factors that enable it to

invade tissues, such as the pore-forming toxin leukotoxin
A.
Porphyromonas gingivalis
P. gingivalis is a gram-negative oral anaerobe and is considered
as a main etiological factor in periodontal diseases.

Several studies have reported a relationship between P. gingivalis

in individuals with periodontal diseases and a critical role of this
bacterium in the pathogenesis.

Multiples virulence factors and extracellular proteases such as

lipopolysaccharide, fimbria, gingipain (cysteine proteases)
resulting in destruction of periodontal tissues.

P. gingivalis was able to invade periodontal ligament stem cells.

Pan, C., Liu, J., Wang, H. et al. Porphyromonas gingivalis can invade periodontal
ligament stem cells. BMC Microbiol 17, 38 (2017).
https://doi.org/10.1186/s12866-017-0950-5
Bacterial Plaque is enough to cause
Periodontal Diseases?
Experimental Gingivitis in Man
The objective of this study was to observe clinical and microbiological changes in a group of patients who completely
discontinued their daily oral hygiene routines.

Twelve (12) subjects were chosen from the School of Dentistry

Once initial registrations were taken, patients stopped using any form of oral hygiene, and during this time,
registrations continued to be taken. As soon as gingival inflammatory changes were clear, between 2-3 weeks,
clinical indices were again measured, and subjects were asked to brush their teeth and to use wood sticks to
massage their gums interdentally. When gingival and plaque indices returned to their baseline values, the experiment
was concluded.

Harald Löe, Else Theilade and S. Börglum Jensen. Experimental Gingivitis in

Man. Journal of Periodontology May-June 1965, Vol. 36, No. 3: 177-187.
 Harald Löe, Else Theilade and S. Börglum Jensen. Experimental Gingivitis in
Man. Journal of Periodontology May-June 1965, Vol. 36, No. 3: 177-187.

Experimental Gingivitis
In the last phase, between 6 and 10 days,
great amounts of vibrios and spirochetes
At the beginning of the non-brushing period, along with large quantities of leukocytes
gram + cocci greatly increased in quantity. and some cocci could be detected.

1-4 days

1-2 days
6-10 days
A few days later, a predominance of When oral hygiene was reinstituted,
filamentous forms and slender rods the plaque in most areas disappeared
were observed, along with quite large in 1–2 days.
amounts of cocci.
This study clearly showed
Conclusions

➢ 1- In Health sub-gingival microbiota is 75 to 90% gram positive.

➢ 2- In disease there is a shift to 40 to 50 % gram negative.
➢ 3- Time necessary for the development of clinical gingivitis: 10 to 20 days.
➢ 4- The prominent bacteria Actinomyces species, especially A.viscosus.
➢ 5- Gram positive bacteria dominates at all times- cocci: 45 - 60%.
➢ 6- Gingivitis can be reversible with oral hygiene (after the initiation of oral hygiene practice there was a
resolution of gingivitis by day 28.
Loe, 1965
Evolution of Plaque hypothesis
Loesche (1900) presented the non-specific
plaque hypothesis stating that periodontal
disease is a result of an increase in the
quantity of plaque and that all bacteria had
the same capacity to cause disease.

This theory was challenged by Socransky

specific-plaque hypothesis (1976 ) in which
he stressed that certain species are more
involved in periodontal destruction.
Ecological Theory
Disease results from a microbial imbalance caused by ecological stress
Marsh 1994
Not necessarily the amount of plaque is consistent with the
expression of the disease.

Only from 9% to 16% the expression of the disease could be

explain by the levels of microorganisms in the plaque alone.
Formation of acquired pellicle

Colonisation of organisms within the dental biofilm should be preceded by the presence
of a condensed layer of macromolecules at the base of the biofilm known as the
acquired pellicle.

This layer was thought to be derived principally from:

➢ salivary glycoproteins
➢ Salivary proteins

that prevents continuous deposition of salivary calcium phosphate.

It forms in seconds after a tooth is cleaned, or after chewing. It protects the tooth
from the acids produced by oral microorganisms after consuming carbohydrates.
 The effect of
Van der Waals and
electrostatic forces
between microbial
surfaces and the film
to create reversible
adhesion to the
teeth.
Early Colonizers

Streptococcus and Actinomyces

species, mostly gram +, were shown to
be early colonizers of tooth surfaces in
the oral cavity.

They adhere to the pellicle and are

necessary for the colonization of other
bacteria associated with periodontal
disease.

Gram-positive early colonizers use sugars

as an energy source.
Once attached, the primary colonizers start to multiply.

The metabolism of these bacteria that attach early will modifies the local environment, for example by making it
more anaerobic condition by consumption of oxygen and the production of reduced end products of
metabolism.

As the biofilm develops, adhesins on the cell surface of secondary colonizers, such as obligate anaerobes, bind
to receptors on bacteria that are already attached by a process termed co‐adhesion or co‐aggregation, and
the composition of the biofilm becomes more diverse.
Secondary Colonizers
After initial colonization, the emerging
biofilm creates regions with lower oxygen
concentrations, allowing for
incorporation of secondary colonizers.

These colonizers include:

Veillonella parvula, which exclusively
metabolizes lactate produced by
early colonizers.
Fusobacterium nucleatum
The orange complex consists of bacteria
that enable crosstalk between bacteria
often referred to as the “bridging
species.” They act as a bridge between
early colonizers and the more
pathogenic bacteria that we find in the
red complex.
Quorum Sensing
Gram-positive and Gram-negative oral bacteria in biofilms can modify their phenotype in response to cell
density through a cell-cell signaling system known as quorum sensing (QS).

It involves small diffusible signal molecules that bacteria synthesize and secrete to coordinate a variety of
their activities—including biofilm formation and growth, adaptation to changes in the oral environment, the
acquisition of a competitive advantage against potential competitors, and the expression of virulence factors
that allow pathogens to cause disease.

Quorum sensing bacteria produce and release chemical signal molecules called autoinducers that increase in
concentration as a function of cell density.
Late Colonizers
Lastly, late colonizers typically consisting
of slower-growing, obligate anaerobes,
such as Porphyromonas gingivalis, can
eventually become a part of the oral
biofilm.

The red complex and Aa complex are

the final bacteria that colonize and lead
to the destruction of the periodontium.
https://youtu.be/xrmTu6LeQd8?si=TfxALUljnqBiSecw
https://youtu.be/xrmTu6LeQd8?si=TfxALUljnqBiSecw
 While bacteria drive and perpetuate the inflammation
the great majority of the tissue breakdown results from the host's inflammatory
processes resulting in loss of attachment and a pocket formation.
It was not until the late 1960’s that the role of
bacteria as an etiologic factor in periodontal
disease was actually accepted.
The confounding issue is the relationship
between inflammation and disease; which
comes first, the immune response or the change
in the homeostatic polymicrobial biofilm
 When the complex ecosystem of the oral biofilm is perturbed, microbial
Dysbiosis ensues.

The dysbiotic microbiota in periodontitis-affected

subgingival sites is characterized by an increased
abundance of pathogens whereas the abundance of
genera considered as beneficial to the host is decreased

Hajishengallis and Lamont, 2012

Dental plaque

Bacterias

Inflammation Calculus
 Periodontal diseases are complex bacteria-induced infections
characterised by an inflammatory host response to plaque
microbiota and their by-products.

Most of these microorganisms have virulence factors capable of causing

tissue destruction both directly, through tissue invasion and the production of
harmful substances, or indirectly, by activation of host defense mechanisms,
creating an inflammatory infiltrate of potent catabolic activity that can
interfere with normal host defense mechanisms.
Periodontitis is a common chronic inflammatory condition that,
may lead to the gradual destruction of the structural
components of the teeth-supporting apparatus.

A number of questions remain to be investigated and answered.

➢ What drives the shift from the localized and contained inflammatory
response of gingivitis to progressive, destructive periodontitis?

➢ When and how does the subgingival microbiome become dysbiotic?

➢ Is it a spontaneous evolution of maturing biofilms or is it driven by the

changing environment mediated by the host response?
Any questions?