Microbiology of Dental Plaque

Dr. Susan Kinder Haake

I. Dental Plaque: Structural, Microbiological and Developmental Characteristics

II. Dental Plaque: Relationship to Dental Diseases
III. Dental Plaque: Recent Reclassification of Periodontal Microorganisms

Dental Plaque: Structural, Microbiological and Developmental

Characteristics
Dental plaque is a soft deposit that accumulates on the teeth. Plaque can be defined as a
complex microbial community, with greater than 10 bacteria per milligram. It has been
estimated that as many as 400 distinct bacterial species may be found in plaque. In
addition to the bacterial cells, plaque contains a small number of epithelial cells,
leukocytes, and macrophages. The cells are contained within an extracellular matrix,
which is formed from bacterial products and saliva. The
extracellular matrix contains protein, polysaccharide and
lipids. Figure 1 shows a microscopic view of a smear of
mature supragingival plaque. Note the presence of a
variety of different bacterial forms (cocci, rods,
filaments, as well as a eukaryotic cell.
10

Inorganic components are also found in dental plaque;

largely calcium and phosphorus which are primarily
derived from saliva. The inorganic content of plaque is greatly increased with the
development of calculus. The process of calculus formation involves the calcification of
dental plaque. The practical consequences of calculus formation are that the deposit is
significantly more difficult to remove once calcified, and it leaves a rough surface on the
root which is easily colonized by plaque. The calculus on the root surface of an
extracted tooth is seen in Figure 2. Note the brown to black coloration of the
subgingival calculus that extends to the apex of the distobuccal root, in contrast to
the whitish color of the supragingival calculus.
Dental plaque can be classified in several different ways. Plaque is classified as
supragingival or subgingival based on its relationship
to the gingival margin. Supragingival plaque is
evident on the tooth above the gingival margin
(Figure 3). Plaque can also be classified by its
relationship to the tooth surface, as either attached or
unattached plaque. The unattached subgingival
plaque is more closely associated with the wall of the
subgingival tissues than is the attached plaque. Lastly,
plaque has been classified by association with disease
state as "health-associated" or "disease-associated". The latter classification is related to
differences in the microbial composition of dental plaque in health versus disease.

The development of dental plaque has been studied in humans as well as non-human
animal model systems. One of the most commonly used models of plaque development
is referred to as the "experimental gingivitis" model (Loe, et al., 1965). This protocol
involves the examination of subjects (usually dental students!) who abstain from any

oral hygiene measures for a period of three weeks. These studies have provided much
information on the structural and microbiological characteristics of dental plaque.
The pellicle is evident as lightly stained material on a
tooth surface when patients use disclosing solution
(Figure 4). A newly cleaned tooth surface is rapidly
covered with a glycoprotein deposit referred to as
"pellicle". The pellicle is derived from salivary
constituents which are selectively adsorbed onto the
tooth surface. Components of the dental pellicle include
albumin, lysozyme, amylase, immunoglobulin A,
proline-rich proteins and mucins. The formation of
pellicle is the first step in plaque formation.
The pellicle-coated tooth surface is colonized by Gram-positive bacteria such as
Streptococcus sanguis, Streptococcus mutans, and Actinomyces viscosus. These
organisms are examples of the "primary colonizers" of dental plaque. Bacterial surface
molecules interact with components of the dental pellicle to enable the bacteria to attach
or adhere to the pellicle-coated tooth surface. For example, specific protein molecules
found as part of the bacterial fimbria (hair-like protein extensions from the bacterial cell
surface) on both Streptococcus sanguis and Actinomyces viscosus interact with specific
proteins of the pellicle (the proline-rich proteins) with a "lock and key" mechanism that
results in the bacteria firmly sticking to the pellicle-coating on the tooth surface
(Mergenhagen et al. 1987). Within a short time after cleaning a tooth, these Grampositive species may be found on the tooth surface.
After the initial colonization of the tooth surface, plaque increases by two distinct
mechanisms: 1 ) the multiplication of bacteria already attached to the tooth surface, and
2) the subsequent attachment and multiplication of new bacterial species to cells of
bacteria already present in the plaque mass. The secondary colonizers include Gramnegative species such as Fusobacterium nucleatum, Prevotella intermedia, and
Capnocytophaga species. A key property of these microorganisms appears to be the
ability to adhere to Gram-positive species already
present in the existing plaque mass. These organisms
would typically be found in plaque after 1 to 3 days of
accumulation. Figure 5 shows the accumulation of
plaque on a tooth surface one day after prophylaxis.
When the structure of dental plaque from this time
period is observed, the presence of a complex array of
bacterial cocci, rods and filaments is apparent.
After one week of plaque accumulation, other Gram-negative species may also be
present in plaque. These species represent what is considered to be the "tertiary
colonizers", and include Porphyromonas gingivalis, Campylobacter rectus, Eikenella
corrodens, Actinobacillus actinomycetemcomitans, and the oral spirochetes (Treponema
species). The structural characteristics of dental plaque in this time period reveal
complex patterns of bacterial cells of cocci, rods, fusiform, filaments, and spirochetes. In
particular, specific associations of different bacterial forms have been observed.

For example, the adherence of cocci to filaments results

in a typical form referred to as "test-tube brushes" or
"corn-cob" arrays and these structures can be seen in
Figure 6. The structural interactions of the bacteria
probably are a reflection of the complex metabolic
interactions that are known to occur between different
plaque microorganisms. One example of this is the

production of succinic acid from Campylobacter species that is known to be used as a

growth factor by Porphyromonas gingivalis. Streptococcus and Actinomyces species
produce formate, which may then be used by Campylobacter species. Fusobacterium
species produce both thiamine and isobutyrate that may be used by spirochetes to
support their growth. The metabolic and structural interactions between different plaque
microorganisms are a reflection of the incredible complexity of this ecological niche.
The overall pattern observed in dental plaque development is a very characteristic shift
from the early predominance of Gram-positive facultative microorganisms to the later
predominance of Gram-negative anaerobic microorganisms, as the plaque mass
accumulates and matures. This developmental progression is also reflected in the shifts
in predominant microorganisms that are observed in the transition from health to
disease. Studies of plaque taken from sites of health or disease and examined either
microscopically or by culturing have demonstrated distinct differences in health versus
disease-associated microbial populations.
Microscopic studies of plaque have examined the presence of
different morphological types ("morphotypes") of bacteria. Figure 7
is a Gram-stained smear of mature subgingival plaque illustrating
different morphotypes (cocci, rods, filaments, spirochetes). These
studies reveal an increase in the presence of motile rods and
spirochetal organisms in gingivitis and periodontitis as compared to
gingival health. A major limitation of studies of bacterial
morphotypes is that many "health-associated" microorganisms are
indistinguishable from "disease-associated" microorganisms (for
example, Streptococcus species and Porphyromonas gingivalis,
respectively). However, cultural studies also reveal characteristic
distinctions between health- and disease-associated plaque. The
percentage of Gram-positive rods and cocci decrease in gingivitisand periodontitis-associated plaque as compared to health-associated plaque. Similarly,
the percentage of microbiota compised of Gram-negative anaerobic species is greatly
increased in gingivitis (approximately 25) and periodontitis (approximately 75) as
compared to health (approximately 13, Slots, 1979). Specific microbial species that are
important in plaque development and disease development are outlined below based on
their categorization by cell wall morphology (Gram-positive, Gram-negative, or
spirochetal) and their physiological status (facultative or anaerobic).

SELECTED BACTERIAL SPECIES FOUND IN DENTAL PLAQUE

Facultative
Gram-Positive

Streptococcus mutans
Streptococcus sanguis
Actinomyces viscosus

Gram-negative

Actinobacillus

Anaerobic

Porphyromonas gingivalis

actinomycetemcomitans
Capnocytophypa species
Eikenella corrodens
Spirochetes

Fusobacterium nucleatum
Prevotella intermedia
Bacteroides forsythus
Campylobacter rectus
Treponema denticola
(Other Treponema species)

99. Microbiology of Dental Decay and Periodontal Disease

Walter J. Loesche

General Concepts
Bacteriology of Dental Infections
The mouth is colonized by 200 to 300 bacterial species, but only a limited number of
these species participate in dental decay (caries) or periodontal disease.

Dental Decay
Dental decay is due to the irreversible solubilization of tooth mineral by acid produced
by certain bacteria that adhere to the tooth surface in bacterial communities known as
dental plaque.
Etiology
Streptococcus mutans is the main cause of dental decay. Various lactobacilli are
associated with progression of the lesion.
Pathogenesis
The tooth surface normally loses some tooth mineral from the action of the acid formed
by plaque bacteria after ingestion of foods containing fermentable carbohydrates. This
mineral is normally replenished by the saliva between meals. However, when
fermentable foods are eaten frequently, the low pH in the plaque is sustained and a net
loss of mineral from the tooth occurs. This low pH selects for aciduric organisms, such
as S mutans and lactobacilli, which (especially S mutans) store polysaccharide and
continue to secrete acid long after the food has been swallowed.
Clinical Manifestations
Caries become intensely painful when the lesion approaches the tooth pulp.
Microbiologic Diagnosis
New, chair-side culture procedures allow for an estimate of the number of S mutans
organisms in saliva.
Prevention and Treatment
The widespread use of fluoride in the water supply, in dentifrices, and in local
applications by the dentist has reduced the prevalence of caries by 30 to 50 percent
among young people in many industrialized countries. In clinical trials, the use of topical
antimicrobial agents to eradicate diagnosed S mutans infections usually significantly
reduces decay.

Periodontal Disease
Definition
Periodontal disease can establish itself when the gums detach from the teeth as a result
of an inflammatory response to plaque.
Etiology

Periodontal infections are usually mixed, most often involving anaerobes such as
Treponema denticola and Porphyromonas gingivalis. The microaerophile Actinobacillus
actinomycetemcomitans causes a rare form known as localized juvenile periodontitis.
Pathogenesis
Plaque bacteria elaborate various compounds (H2S, NH3, amines, toxins, enzymes,
antigens, etc.) that elicit an inflammatory response that is protective but also is
responsible for loss of periodontal tissue, pocket formation, and loosening and loss of
teeth.
Clinical Manifestations
There is no apparent pain until very late when abscesses may occur. Bleeding gums and
bad breath may occur.
Microbiologic Diagnosis
Microbiologic diagnosis is usually not sought. Spirochetes and other motile organisms
are found upon dark-field microscopic examination. Immunologic reagents, DNA probes
and enzyme assays have been developed for P gingivalis, T denticola, Bacteroides
forsythus, A actinomycetemcomitans and other organisms.
Prevention and Treatment
Daily toothbrushing and regular professional cleanings by the dentist appear to be
adequate to prevent periodontal disease. Rigorous debridement of tooth surfaces is the
standard treatment. Often, some form of surgery is used to improve access to root
surfaces. Recent studies suggest that short-term use of antimicrobial agents, especially
metronidazole and doxycycline, is beneficial.

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The University of Texas Medical Branch at Galveston