Periodontal Microbial Ecology

Copyright Blackwell Munksgaard 2005
Periodontology 2000, Vol. 38, 2005, 135187

Printed in the UK. All rights reserved
PERIODONTOLOGY 2000
Periodontal microbial ecology

S I G M U N D S. S O C R A N S K Y & A N N E D. H A F F A J E E
The authors have taken the liberty of presenting this

manuscript in two parts. The first is a brief primer
on microbial ecology, because, although the importance of microbial ecology in periodontal diseases is
widely recognized, most of us do not know precisely
what is meant by the term. The second section is a
rather extensive overview of current studies of oral
microbial ecology based almost entirely on recent
in vivo studies.
Principles of microbial ecology

Microbial ecology is concerned with the interrelationships between microorganisms and their environments. Habitat ecologists, including periodontal
microbiologists, examine the microorganisms of a
particular habitat and attempt to analyze the effects
of the microorganisms on their environment and the
influence of the habitat on its residents. Many of the
principles of microbial ecology were outlined in a
superb monograph by Alexander (2) and will be
briefly described below along with some periodontally relevant examples to highlight some of the
points.
The ecosystem
A key concept in microbial ecology is the ecosystem.
An ecosystem is the complex of organisms in a specified environment and the nonmicrobial surroundings with which the organisms are associated. The
ecosystem includes the assemblage of species and
the organic and inorganic constituents characterizing
that particular site. Each ecosystem has a collection
of organisms and nonmicrobial components unique
to it and it alone. The organisms inhabiting a given
site constitute a community. The assemblage of
organisms constituting a community contains populations of individual microbial species. This leads to
a hierarchy from ecosystem to community to population to the single cell. One of the goals of this issue of
Periodontology 2000 will be to define the assemblage

of species in the periodontal habitat, to determine
how changes in the habitat affect the community and
how the community affects its habitat.
Habitat and niches

The habitat is the site at which a population or
community grows, reproduces or survives. The role of
an organism in a habitat is its niche. Niche does not
connote location but rather function. A species can
have one niche in one habitat and a different niche in
another habitat.
Microbial succession
In a developing ecosystem, certain species termed
pioneer organisms colonize first. These species are
often replaced by other species after they have
altered the habitat, making it suitable for colonization
by other species. There are two kinds of microbial
succession. In autogenic succession, the sequence of
species is brought about because the resident populations alter their surroundings in such a manner that
they are replaced by species better suited to the
modified habitat. In allogenic succession, one type
of community is replaced by another because the
habitat is altered by nonmicrobial factors such as
changes in the physical or chemical properties of the
region or changes in the host. Factors contributing to
succession are:
provision by one community of a nutrient that
confers an ecologic advantage to the species in
the next stage of succession;
the making available by one population of a
constituent present in insufficient supply to allow
for growth of a later population;
alteration in concentration of an inorganic nutrient;
modification of heterogeneous substrates such as
animal tissue;
an autointoxication effect;
135
Socransky & Haffajee
elimination of an organism by physical means;

the appearance of barriers due to environmental
feedback.
The development of gingivitis provides an example
of microbial succession as well as species habitat
interaction. Loe et al. (90) and Theilade et al. (170)
demonstrated that dental plaque caused gingivitis. It
was shown that withdrawal of toothbrushing for
28 days in periodontally healthy volunteers resulted in
the rapid accumulation of plaque on the teeth.
Gingivitis developed in all subjects in 1021 days.
Re-establishment of oral hygiene procedures removed
the plaque and reversed the gingivitis. Stained smear
preparations obtained during the 28-day time course
revealed initial colonization by gram-positive cocci
and rods, followed by gram-negative cocci and rods,
then fusobacteria and filaments, and finally spirilla
and spirochetes. Appearance of clinical gingivitis
related to the appearance of the gram-negative forms.
These data were in accord with other studies that
demonstrated microbial succession in plaque development (140, 161, 188). The Danish studies associated
certain bacterial morphotypes with a change in the
clinical status of the site, i.e. the development of
gingivitis. Data presented below demonstrate that
species of the red and orange complexes (described
later) are more prevalent and found in higher numbers
in lesions of established gingivitis. The same taxa are
even more prevalent and found in higher numbers in
suppurating lesions. Thus, a change in plaque
composition appears to affect the habitat, resulting in
clinically apparent gingivitis. Other studies indicate
that a change in habitat such as the development of

gingivitis also affects plaque development. Plaque
accumulated much more rapidly after cleaning, at
sites that exhibited gingivitis than at sites that were
periodontally healthy (25, 132). Thus, it is possible to
postulate a scheme of microbial succession followed
by reciprocal hostbacterial interaction (Fig. 1). The
members of each color-coded complex are described
in a later section. Initial colonization appears to
involve members of the yellow, green, and purple
complexes along with Actinomyces species. This leads
to autogenic succession in which members of the
orange and then red complexes become more
dominant. The presence of increased levels of the last
two complexes is hypothesized to lead to a change in
the habitat, manifested clinically as gingivitis. The
gingivitis in turn favors further proliferation by
members of not only the orange and red complexes,
but probably members of the early colonizing species
as well. This cycle could be broken in a number of
ways. The first way would be to eliminate all plaque;
this partially successful strategy is the one most
commonly employed today. The second would be to
eliminate members of the red and or orange
complexes. This would probably limit gingivitis and its
feedback effect of greater plaque development. The
third would be to decrease gingivitis by a non antimicrobial approach, leading to decreased plaque
accumulation and possibly diminished red and
orange complex development. It is worth noting that
the effect of a prevention or treatment regimen would
be an example of allogenic succession.
Microbial succession
Purple
Actinomyces sp.
Yellow
Green
Orange
Fig. 1. Hypothesized relationship between the addition of

species during microbial succession leading to the development of gingival inflammation. In turn, the increased
136
Reciprocal interaction
Red
Gingivitiis
inflammation would result in increased growth of

colonizing species.
Factors limiting colonization

Certain factors limit colonization. One obvious limitation is the available physical space. Preemptive
colonization is a second situation in which prior
colonization by one species excludes another.
Exclusion results from the occupation of a niche by
one species that might have been taken by the other.
The first species performs the activities, uses the
nutrients andor occupies the physical sites of
the excluded species. Environmental resistance is the
restriction in numbers of individuals or biomass
imposed by physical, chemical or biological factors of
the ecosystem. The condition holding the population
in check is considered to be a barrier. Preemptive
colonization is a major means of exclusion of latecomers, and it is, together with the physical and
chemical barriers in the locale, one of the components of environmental resistance. Any periodontal
investigator who has attempted to introduce a test
species into periodontal plaque can attest to the
effectiveness of these barriers.
Dissemination of organisms
In order for organisms that are restricted in nature to
live in association with a suitable host to continue to
survive, their dispersal is essential. Dissemination
can be via active or passive means. For example,
growth or motility can actively move a species from
one site to another within the oral cavity. Passive
dissemination occurs both within the oral cavity and
Spirochetes
60
154
from subject to subject. Microorganisms show centers of dispersal, regions from which species are
spreading or have spread. At this site, conditions are
favorable for an increase in density of the species and
the site serves as a point from which the species can
emanate. This site is referred to as a reservoir of
infection. The greater the efficiency of the dispersal
mechanism, the smaller the number of organisms
needed for dispersion. Oral species might disseminate from subject to subject via droplet infection or
infection via inanimate objects. The tools of
molecular epidemiology have been used to demonstrate vertical transmission (parent to offspring) for
Actinobacillus actinomycetemcomitans (124, 125, 128)
and Porphyromonas gingivalis (125), as well as horizontal transmission from spouse to spouse for
P. gingivalis (143, 175). Another example of transmission comes from early studies of acute necrotizing ulcerative gingivitis, also known as Trench
mouth. This disease was transmitted among troops in
World War I and later to the civilian population (154).
Riviere et al. (141) found that spirochetes and
P. gingivalis were more prevalent in diseased sites of
diseased subjects than in healthy sites of diseased
subjects (Fig. 2). Of major significance was the
additional finding that healthy sites of diseased subjects harbored these species more frequently than
healthy sites of healthy subjects. This finding has
been confirmed in other studies, as will be described
below. The authors speculated that the deeper
pockets of diseased subjects were acting as reservoirs
for spread of infection to healthy sites. This is indeed
P. gingivalis
16
342
Health
% sites
Gingivitis
45
12
Early periodontitis
1214 360
408
Advanced periodontitis
342
30
363
360
1214
4
136
363
609
609
15
268
154
136
1708
1708
268
408
0
0
Health
Gingivitis
11
Early
Periodontitis
61
Advanced
Periodontitis
29
Fig. 2. Bar charts of the frequency of detection of spirochetes and P. gingivalis in sites and subjects with different
clinical characteristics. Spirochetes were identified using
phase contrast microscopy and P. gingivalis by immunocytochemistry. The numbers over the bars indicate the
Health
Gingivitis
11
Early
Periodontitis
61
Advanced
Periodontitis
29
number of samples examined. The bar colors indicate

the characteristics of the sampled site. The labels under
the bars indicate the classification of the subject, and the
numbers under the bars indicate the number of subjects
examined. Data adapted from (141).
137
a possibility, although alternative hypotheses are

possible.
Infectious disease
Infectious diseases represent a category of populationenvironment interactions involving a host plus a
microorganism with the potential for both colonization and pathogenesis. From the ecologic standpoint
the governing feature of the ecosystem is the living
animalhuman. The host must be colonizable, i.e. it
must be receptive to invasion by the particular disease agent. Not all higher animals are colonizable by
all pathogenic bacteria, fungi or viruses. Three kinds
of barriers underlie lack of receptiveness:
the barriers of the nonreceptive host;
the factors associated with the resistance of the
receptive host prior to its first contact;
the obstacles to further bacterial development or
activity that appear as a consequence of infection.
In effect, there is an environmental feedback, a
modification of the habitat resulting from the presence of one or more bacterial populations, a change
that can affect the size, activity or survival of the
invading population or one or more segments of the
community. The production of antibody to colonizing species is an example of environmental feedback. This will be discussed in greater detail later in
this chapter.
Successful colonization
Success in colonization of a species depends on
presence at the colonizable place at the correct
time;
possession of survival capability permitting prolonged viability in deleterious circumstances;
ability to obtain all nutrients from the ecosystem;
capacity to tolerate all of the ecologically significant nonmicrobial factors of the environment, e.g.
pH, O2 levels, temperature, osmotic pressure,
oxidation reduction potential;
possession of mechanisms to overcome or cope
with environmental resistance attributable to
viable hosts;
ability to overcome or cope with environmental
resistance attributable to species already in the
habitat;
capability to grow as rapidly as ones neighbors;
ability to adhere to appropriate surfaces.
The role of some of these factors in the formation of
microbial complexes was discussed in Socransky
et al. (156).
138
The climax community

The interaction between the microbial and nonmicrobial components of an ecosystem ultimately leads
to a form of stabilization in which microbial and
nonmicrobial forms exist in harmony and equilibrium with their environment. This is the climax
community. This remains reasonably stable over
time and reflects a dynamic situation in which cells
are dying and being replaced. The climax is essentially a self-replicating entity that reproduces itself
with remarkable fidelity. Given the same initial
physical and chemical site characteristics or identical
hosts, the same general successional sequences will
be initiated and fostered, giving rise to remarkably
similar climax communities. The climax can be
modified from time to time by exogenous forces. The
equilibrium tends to be restored as the habitat
returns to its original state. At other times, environments may be irreversibly altered, leading to a different steady state and a different climax community.
The climax contains many niches and the species
occupying each is uniquely fit, at least among species
having access to the locale, for the function associated with the niche. Inasmuch as there are numerous
niches or potential functions, particularly when there
is an intermeshing of food chains, many physiologically different groups of organisms can coexist
indefinitely.
Most developed dental plaques represent climax
communities. Minor perturbations probably result in
a re-development of the same community, albeit with
somewhat altered proportions of species. Preventative or therapeutic strategies probably encounter a
tendency of the ecosystem to return to the original
equilibrium after termination of treatment. This
tendency can be frustrating to the clinician in that it
necessitates a prolonged maintenance phase after
therapy. Often, we wish for more profound changes
in the periodontal microbiota after therapy. However,
as the old adage states: be careful what you wish for,
because you might get it. More permanent changes
can be brought about in the microbiota by employing
potent exogenous forces of a persistent nature. The
microbiota of a recent refractory patient is instructive. The subject is a dental professional who exhibited initial signs of periodontitis about 10 years ago.
He was treated initially by scaling and root planing and
later by surgery. The disease continued to progress,
leading to the loss of five teeth in 2 years accompanied
by a very painful symptomatology. He took in
sequence: systemic tetracycline, ampicillin, amoxicillin + metronidazole, clindamycin, ciprofloxacin, long-
Current studies of oral microbial

ecology
BULK FLUID
The 215 cm2 surface area of the oral cavity (23) presents numerous surfaces for microbial colonization.
The diverse mucosal surfaces are lined by different
types of epithelium, while hard surfaces are presented by the teeth or various types of replacements.
These surfaces are continuously bathed in a bulk
fluid, primarily saliva, and thus provide excellent
environments for biofilm development. The microorganisms that colonize these surfaces produce biofilms of differing complexities depending on intraoral
location, genetic background and environmental
factors individual to each subject. As many as 700
bacterial species may colonize the surfaces of the oral
cavity (120). It has been shown that marked differences in microbial composition can occur from person to person, from one type of intraoral location to
another in the same subject (e.g. tongue dorsum vs.
supragingival plaque) and from similar types of
locations in the same subject (e.g. two periodontal
pockets). As complex as this microbiota may appear,
the approximately 500 species that may be detected
in subgingival plaque are a miniscule fraction of the
estimated billion or more bacterial species present on
Earth that potentially could have colonized the oral

cavity. Clearly, potent forces control the establishment of the oral microbiota, govern its composition
and influence its re-development once the ecosystem
has been disturbed. It is the intent of this section to
describe some of the factors that influence the
development and composition of human intraoral
biofilms and that lead to the variation that may be
seen from subject to subject and from site to site
within an individual.
The study of hostmicrobial relationships is not
easy, in part because of the complexity of the
microbiota, and in part because of the multiplicity of
influences that impact on the microbial composition
of a biofilm in a given site. All biofilms consist of
three components (Fig. 3): the surface needed for the
attachment of the biofilm, the biofilm community
itself, and the bulk fluid that passes over the biofilm,
providing nutrients to the colonizing organisms,
removal of waste products and transport of cells to
new colonization sites. Each of these components
may be altered by local or subject level factors that
may influence the microbial composition of the
colonizing biofilm. For example, the nature of the
surface presented for colonization may be influenced
by the type of tissue presented, the genetic background of the subject (which might alter surface
SURFACE
term low dose doxycycline and various local agents

including Actisite, chlorhexidine, and triclosan over a
period of about 4 years. When he was sampled, his
microbiota had been simplified so that Streptococcus
oralis made up over 95% of the cultivatable microbiota. Spirochetes, motile forms, Fusobacterium,
Veillonella, Prevotella, Capnocytophaga, and Eikenella were undetectable by culture or DNA probe. A
new climax population had been established in this
subject that prevented establishment of additional
taxa. Unfortunately, this climax population was not
host-compatible. Each of the above treatments presumably lowered the numbers of the new climax
population and relief was achieved for 56 weeks.
However, the same species would re-emerge after
therapy (the new climax community had no competition) and damage to the habitat would resume. This
case reinforces the importance of controlling pathogens but without deleterious changes in the remaining ecosystem. It is essential to clearly define host
compatible ecosystem(s) to provide desired therapeutic end points. The effects of various forms of
therapy on the subgingival climax community will be
described in Haffajee & Socransky (65).
BIOFILM
Fig. 3. Components of a biofilm.
139
receptors), the possible introduction of artificial

surfaces, hygiene practices, etc. Given this heterogeneity, it is essential to examine large numbers of
samples from similar and different locations to
attempt to discriminate the local and host-level
factors that govern the composition of human oral
biofilms. Critical to our understanding of these
factors is the recognition that these relationships are
not one-way. The host may influence the microbiota,
but in turn the microbiota influences the host on a
local and perhaps systemic level. The bacterial
colonization that elicits a local inflammatory
response is in turn influenced by the inflammatory
response which in turn You get the picture. The
interactions between bacterial species in a biofilm
and between bacterial species and the nonbacterial
habitat are dynamic. They reflect a back and forth
interplay between host and colonizing species. When
investigators sample a range of biofilms, they get a
series of snapshots at individual points in time of this
dynamic relationship, which they try to integrate into
a coherent picture. Understanding of the ecologic
relationships within intraoral biofilms and between
biofilm composition and the host has been slowed by
the difficulty in obtaining sufficient snapshots of the
microbial composition of biofilms taken from carefully monitored clinical situations. The major limiting
factor has been the lack, until recently, of microbial
techniques that are specific and rapid enough to
permit evaluation of the large numbers of samples
needed for meaningful in vivo studies. The next
section will provide an overview of the techniques
that have been employed to study the composition of
intraoral biofilms and will describe the development
of methodologies in recent years that permit meaningful ecologic studies to take place.
Detection and enumeration of bacterial

species in complex biofilm samples
The study of infectious diseases has traditionally
focused on one or a small number of pathogens in a
given infectious disease. Even when samples are
taken from areas where complex mixtures of species
coexist, emphasis has been placed on seeking a limited number of likely pathogens from that site. The
remaining organisms are often considered to be
normal flora. In most instances such species might
well be host-compatible, common residents of the
sampled site; however, in some instances, these
species might contribute to the pathogenesis of the
observed condition. In addition, the absence of some
host compatible species may be as important in
140
disease initiation or progression as the presence of

one or more pathogenic species. Examination of
complex mixtures of microorganisms has been
hampered by at least two factors. The first is the
tradition of focusing on a small number of species
thought to be pathogenic. The second is the absence
of useful, rapid identification techniques to evaluate
large numbers of bacterial species in large numbers
of samples taken from areas where complex microbiotas exist. This capability has been slow to develop
and thus studies of the complex ecologic relationships among bacterial species and between bacterial
species and the host as well as studies of the effects of
different therapies on the subgingival ecosystem was
delayed until recent years.
The earliest studies of subgingival biofilm composition involved the techniques of light microscopy.
These techniques were reasonably rapid, but limited
in the precision of identification of individual bacterial species. Thus, while about nine morphotypes
could be conveniently recognized (88), there were
actually as many as 500 bacterial species in oral
biofilm samples (120). Light microscopic examination of wet mount preparations became popular for a
number of years as part of monitored, modulated
periodontal therapy in which eradication of motile
forms including spirochetes was employed as an aid
to guide the intensity of periodontal therapy (70). The
development of the electron microscope permitted
examination of biofilm samples with greater resolution. Electron microscopic techniques allowed a
somewhat finer distinction of microbial groups based
on cell wall ultrastructure and the presence and
arrangement of various appendages to the microbial
cell such as axial filaments or flagella. Electron
microscopy by itself could not precisely identify a cell
to the species level; however, in combination with
immunocytochemical techniques or in situ hybridization, the technique permitted precise localization
of bacterial cells in relation to each other and the host
when block sections were taken from the subjects
(72, 110113). The great strength of the microscopy
techniques, including the promising confocal microscopy, is the delineation of spatial arrangements of
the organisms. The great weakness of these techniques from an ecologic perspective is that they are
slow and labor intensive and thus limit the number of
samples that can be examined. In addition, precise
speciation using immunologic or hybridization
techniques can only be performed for a very limited
number of species in any given sample.
For many years, the major technique available
to researchers to identify plaque bacteria was to
cultivate the organisms and identify the species by

their phenotypic traits; a rather time-consuming,
labor-intensive, and expensive undertaking (Table 1).
As a result, relatively few plaque samples in small
numbers of subjects could be examined. For example, in studies performed at The Forsyth Institute
between 1982 and 1988, 300 subgingival plaque
samples from actively progressing periodontal
lesions before and after therapy were evaluated using
cultural techniques (37, 62). At the time, this
was considered a large scale study, and indeed the
characterization of approximately 15,000 isolates in a
6-year period was a major undertaking. Nonetheless,
only two or three samples were taken per subject, at
each time point, from a total of 88 subjects. The
classic studies of Moore & Moore (105), in which they
examined the composition of subgingival plaque
samples in periodontal health and different states of

periodontal disease, employed cultural techniques to
examine over 17,000 isolates from over 600 periodontal sites. This represented a huge body of work
on, by current standards, a limited number of samples. Despite their limitations, these studies and
other cultural studies of the 1970s and 1980s defined
the species thought to be important in the initiation
and progression of periodontal diseases as well as
species thought to be host-compatible or beneficial.
The major strength of culture is that, in theory, the
majority of the bacterial species sampled will grow
and be identified. However, difficult to grow species
and uncultivable species, such as many of the
spirochetes, will not be detected by this technique.
Other species require special conditions for their
growth. If these conditions are not met, their
Table 1. Methods to determine microbial composition of oral samples

Method
Strengths
Weaknesses
Application
Predominant
cultivable
Can detect unrecognized

Extremely time consuming
species; provides cultures and expensive; often
for further analysis.
difficult to speciate cultures.
Studies of new ecosystems
Selective media
Modest numbers of
samples for modest
numbers of species.
Few useful selective media

available; often media are
too selective or not selective
enough; expensive.
Studies of limited scope

involving 110 species in
modest numbers of samples.
Immunofluorescence Specificity; reasonably

rapid.
Limited number of useful

antisera; small numbers of
samples may be run.
Maybe more useful for

diagnostic than ecologic
or treatment studies.
PCR
Sensitivity; specificity.
Not quantitative (presence

absence); expensive;
dependent on amplification.
Detection of species in a
subject (prevalence);
detection of low numbers
of species post therapy.
Real time PCR
Sensitivity; specificity;
quantitative.
Comparatively slow; very

expensive; limited in
numbers of samples species.
Studies where quantitation

of a very limited range of
species in low to modest
numbers of samples is required.
DNADNA
hybridization
Sensitivity; specificity;
quantitative.
Confined to species for which

probes are available; modest
number of species for modest
numbers of samples.
Seeking a specific set of

species in modest
numbers of samples.
Checkerboard
DNADNA
hybridization
Sensitivity, specificity,
quantitative; can use
entire sample; large
numbers of species
and samples;
inexpensive.
Confined to species for which

Studies of large numbers
probes are available; possibility of species in large numbers
of cross-reactions.
of samples, e.g. ecology
and treatment studies.
16S rDNA
amplification
cloning
Detection of cultivable
and uncultivable
species; phylogenetic
positioning of taxa.
Extremely expensive; extremely

small numbers of samples.
Survey a range of species that

may occur in specific habitats.
141
numbers will be severely underestimated. For

example, the importance of the recognized periodontal pathogen, Tannerella forsythia (Bacteroides
forsythus), was not confirmed by culture until the
unusual growth requirements of this organism were
determined (182). However, it took immunofluorescence techniques to initially indicate the relatively
high prevalence of T. forsythia in subgingival plaque
samples of chronic periodontitis subjects (52).
Despite its drawbacks, culture still has a place in
studies of periodontal microbiology, particularly for
the identification of organisms in unusual clinical
conditions and in situations where pure cultures are
needed for additional analysis.
Light microscopy, electron microscopy, and cultural techniques have largely been supplanted for
studies of microbial ecology and periodontal treatment by more rapid techniques. Antibody-based
methods were among the first to be used to enumerate specific species of microorganisms without
their cultivation. Immunofluorescence techniques
and enzyme-linked immunosorbent assay (ELISA)
techniques have been successfully employed to
examine a limited range of bacterial species in larger
numbers of plaque samples than had been examined
using cultural techniques (8, 46, 51, 52, 56, 97, 187).
These techniques are dependent on the specificity of
the developed antibodies to specific taxa. Properly
prepared and evaluated monoclonal or polyclonal
antisera provide a sensitive and specific method of
detecting specific bacterial species in dental plaque
samples. These techniques have the advantage that
samples do not have to be cultured for enumeration,
and they are rapid and less expensive than culture.
However, they are limited to species for which reagents have been developed. In addition, it is difficult
to use these techniques, particularly immunofluorescence techniques, to evaluate large numbers of
species in very large numbers of plaque samples.
Recently, however, Singleton et al. (152) have
described a fully automated microscopic bacterial
enumeration method to permit larger numbers of
samples to be evaluated. Another disadvantage of
antibody-based techniques is the time required to
develop and validate specific antisera to new species.
In the last decade, polymerase chain reaction
(PCR) has been used to detect the presence of
selected bacterial species in subgingival plaque
samples (5, 82, 92, 101, 102, 172). Given the appropriate primers, this method is rapid and simple and is
able to detect very small numbers of cells of a given
species. It has the disadvantage of not providing
142
quantitative data (until recently) (69, 95), but usually

indicates the presence or absence of a species in the
sample. For some applications, this would be sufficient. For applications where the relative levels of
species are important, PCR may not be ideal. In
addition, examining large numbers of species in large
numbers of samples is difficult and may not be cost
effective. Real time PCR has been added to the
potential methods for examining the composition of
biofilm samples (69, 95). This method has the
advantages of being specific, sensitive, and providing
quantification of the level of selected species in biofilm samples. However, the technique suffers similar
limitations to conventional PCR in that it is currently
not suitable for screening large numbers of samples
for large numbers of bacterial species.
DNA probes provide another approach to identification and enumeration of bacterial species in
complex communities such as dental plaque.
Oligonucleotide probes are short probes designed to
identify unique regions of DNA within cells of a
given bacterial species. It has been suggested that
these probes are highly specific and the likelihood of
cross-reactions with other species is very low. A
number of studies have utilized these probes to
identify periodontal bacteria (47, 103, 104, 106).
Because they target a limited segment of the DNA of
an organism, oligonucleotide probes tend to be less
sensitive for the detection of low numbers of
bacteria than whole genomic probes. However,
oligonucleotide probes directed towards targets that
have multiple copies in the cells such as 16S rRNA
have the potential to be more sensitive. To date,
there have been no large scale studies of the
subgingival microbiota that have utilized oligonucleotide probes for the detection and enumeration of
a wide range of bacterial species.
Whole genomic DNA probes have been used
extensively in studies evaluating the composition of
subgingival plaque (24, 61, 94, 116118, 156, 183,
184). Whole genomic probes are constructed using
the entire genome of a bacterial species as the target
and thus can be quite sensitive. One of the criticisms
of these probes is that the use of the entire genome
may increase the probability of cross-reactions
between species because of common regions of DNA
among closely related species. Other concerns have
been that the whole genomic DNA probes might not
detect all strains of a given species and that the
probes would have a low sensitivity in terms of the
numbers of cells that they detect. Investigations at
The Forsyth Institute, however, using whole genomic
DNA probes have indicated that many of the
concerns regarding their use are unjustified or can be

overcome (159).
DNA probes can be very effective for the detection
of bacterial species, but when employed in the typical
format (one probe against multiple targets), only
limited numbers of probes can be employed to
enumerate relatively large numbers of samples.
Checkerboard format procedures, whether employing
direct or reverse hybridization procedures, can extend
markedly the number of samples evaluated for a wide
range of bacterial species. Paster et al. (9, 122) have
combined the potential high specificity of the oligonucleotide probe approach with a reverse capture
checkerboard format. The investigators overcame the
sensitivity issue of the oligonucleotide probe by
amplifying the 16S rDNA region of DNA extracted
directly from biofilm samples using consensus
primers (primers that will permit amplification of a
wide range of bacterial taxa). Oligonucleotide probes
specific for different species are fixed in parallel lanes
on a nylon membrane and individual samples which
were labeled by digoxigenin during the PCR amplification are hybridized in parallel channels at right
angles to the probe lanes. This technique permits the
detection of at least 28 taxa in 44 samples on a single
nylon membrane (9). The technique has the advantages of being rapid, relatively inexpensive, and
potentially specific to species, genus or family level (at
the choice of the investigator). It also provides the
advantage of detecting uncultivable species. It has the
disadvantage of not permitting accurate quantification and being somewhat more expensive than the
direct checkerboard technique, described below,
because of the need to amplify the sample using PCR.
In addition, amplification by PCR might introduce
some bias into the results because of possible differences in amplification of target species in the
biological sample.
The direct checkerboard DNADNA hybridization
technique (Fig. 4) offers a number of advantages for
the study of multiple species of bacteria in large
numbers of samples containing complex mixtures of
microorganisms. As this technique provides the data
for most of the examples provided in this chapter, it
will be described in somewhat more detail. It must
be emphasized that this technique is not the only
method of value for the study of the composition of
oral biofilms. However, the capability of studying
large numbers of samples for large numbers of
species does provide a major benefit for studies of
oral microbial ecology. The checkerboard technique
is rapid, sensitive, and relatively inexpensive. It
overcomes many of the limitations of cultural
microbiology, including loss of viability of organisms

during transport, the problem of enumerating difficult to cultivate (or even uncultivable) species, and
the difficulty encountered in speciating certain taxa
that are difficult to grow or exhibit few positive
phenotypic traits. Another advantage is that the
entire sample may be employed without dilution or
amplification (with appropriate regard to total
sample size) overcoming problems in quantification
imposed by either serial dilution (used in culture) or
PCR amplification procedures. The technique in its
original format evaluates 28 samples for their content of 40 taxa (i.e. 1120 bacterial counts) on a single
15 15 cm nylon membrane. The membranes may
be stripped and re-probed with a new set of 40
different DNA probes if desired. The technique is
sensitive since it can routinely detect 104 cells of a
given species in a sample and conditions of
hybridization and detection can be altered to detect
as low as 103 cells (31). For the most part, the whole
genomic DNA probes have been found to be
remarkably specific; 93.5% of probe : heterologous
species cross-reactions were less than 5% of the
homologous probe signal (159).
The checkerboard DNADNA hybridization technique does have limitations. The technique can
detect only species for which DNA probes have been
prepared. Thus, this method would not detect novel
pathogens or environmentally important species that
might be detected in culture or by other molecular
techniques. The probes must be used to detect
organisms in samples of the appropriate size. Probes
optimized to detect species in the 104)107 range
often will provide cross-reactions if much larger
samples are employed.
When properly employed, checkerboard DNA
DNA hybridization and other rapid microbiological
techniques permit investigation of etiologic, therapeutic, and ecologic problems which could not be
approached by other means. The data from clinical
samples presented in this chapter demonstrate the
feasibility of describing the microbiota in sites with
different local clinical conditions as well as in subjects with different systemic backgrounds, different
periodontal disease states or health. In addition,
species abundance, species diversity, and community
structure can be computed from data derived using
this technique (156). As new and improved DNA
probes are developed, and rapid microbiological
techniques are employed, an understanding of the
ecologic relationships of complex microbial communities can be developed at a level hitherto beyond
our reach.
143

5
11 12 13 14 15 16 17 21 22 23 24 25 26 27 31 32 33 34 35 36 37 41 42 43 44 45 46 47 10 10
A. naeslundii I
S. constellatus
E. nodatum
P. gingivalis
A. actinomycetem.
F. nuc. ss vincentii
C. rectus
T. socranskii
E. saburreum
P. micros
V. parvula
A. naeslundii II
S. anginosus
S. sanguis
A. gerencseriae
S. oralis
C. ochracea
A. israelii
S. intermedius
T. denticola
P. nigrescens
A. odontolyticus
F. nuc. ss polymorphum
C. showae
F. periodonticum
N. mucosa
F. nuc. ss nucleatum
C. gingivalis
S. gordonii
T. forsythia
S. noxia
P. acnes
P. melaninogenica
S. mitis
E. corrodens
G. morbillorum
C. sputigena
L. buccalis
C. gracilis
P. intermedia
Fig. 4. Example of checkerboard DNADNA hybridization
being used to detect 40 bacterial species in 28 subgingival
plaque samples from a single patient. The vertical lanes are
the plaque samples numbered from 11 (maxillary right
central incisor) to 47 (mandibular right second molar). In
this subject, teeth 16, 17, 21, and 37 were missing. The two
vertical lanes on the right are standards containing either
105 or 106 cells of each test species. The horizontal lanes
contained the indicated DNA probes in hybridization buffer.
A signal at the intersection of the vertical and horizontal
lanes indicates the presence of a species. The intensity of the
signal is related to the number of organisms of that species
in the sample. In brief, samples of plaque were placed into
individual Eppendorf tubes and the DNA released from the
The first component: microbial

composition of subgingival biofilms
Total numbers of subgingival bacteria in
periodontally healthy and diseased subjects
The first microbial ecology question that might be
asked is how many bacterial cells are present in
144
microorganisms by boiling in NaOH. After neutralization,

the released DNA was transferred to the surface of a nylon
membrane using the 30 channels of a Minislot device
(Immunetics, Cambridge, MA). The DNA was fixed to the
membrane by UV light and baking and placed in a Miniblotter 45 (Immunetics) with the lanes of DNA at right angles
to the 45 channels of the Miniblotter device. Whole genomic
DNA probes labeled with digoxigenin were placed in
hybridization buffer into 40 of the lanes and hybridized
overnight. After stringency washing, the signals were
detected using phosphatase-conjugated antibody to digoxigenin and chemifluorescence substrates. Signals were
compared to the standards using a Storm Fluorimager and
converted to counts. Reprinted with permission from (159).
subgingival biofilms in both periodontally healthy

and diseased subjects? An estimate of total subgingival bacterial numbers may be derived from data
from Sharawy et al. (149). These investigators carefully harvested all of the subgingival plaque (or as
much as possible) from the subgingival tooth surfaces of half of the mouth in 14 periodontally
healthy and 21 periodontitis subjects. The average
dry weight of the samples was 1.6 0.8 and

8.3 3.9 mg, respectively, for the two clinical
groups. This translated to about 8.0 and 41.5 mg wet
weight per half mouth or a total of 16 and 83 mg
wet weight of plaque from periodontally healthy and
periodontitis subjects, respectively. Since the average total microscopic count of organisms in subgingival plaque is 2.1 108 per mg wet weight (153),
the total number of microbial cells in subgingival
plaque from periodontally healthy subjects may be
estimated at 33.6 108 and from periodontitis subjects at 174.3 108, with considerable subject to
subject variation. It is interesting that the full-mouth
mean counts differed by a factor of only 5,
since clinicians sometimes can remove very large
amounts of plaque from some subjects with periodontitis. However, it must be recognized that massive subgingival plaque accumulation occurs in only
a small number of subjects and that most periodontal sites in most subjects with periodontitis are
healthy, i.e. exhibit minimum disease and little
subgingival plaque.
Phylum
Obsidian pool
TM7
Deferribacteres
Spirochaeta
Fusobacteria
Species abundance
One of the first steps that an ecologist would take in
studying any ecosystem would be to survey the range
and nature of the species that exist in the habitat of
interest. This has been admirably described by Paster
et al. (121). They indicated that approximately 500
species may be encountered in subgingival biofilms
and they have summarized the nature of the taxa
found. Figure 5 (from [121]) describes the 10 phyla
that have been detected in subgingival plaque samples, provides examples of known species from these
phyla, and demonstrates that more than half of the
taxa detected were of novel species. However, it is
clear that the approximately 500 taxa that may be
encountered are not uniformly distributed in subgingival biofilm samples, i.e. some taxa are detected
with far greater frequency and in greater numbers
than others in any oral habitat of interest. The frequency of detection of the cultivable and as yet
uncultivated taxa in samples from periodontal sites
(121) is presented in Fig. 6. Twenty-six of the 306 taxa
N known N novel
species phylotypes
0
0
0
1
5
8
10
45
Known species detected

in at least 4 subjects
T. medium, T. denticola, T. maltophilum

T. lecithinolyticum, T. socranskii
F. naviforme, F. nuc ss nucleatum,
F. nuc ss polymorphum, F. animalis
L. buccalis
A. naeslundii 2, R. dentocariosa,
C. matruchotii, Atopobium parvulum
A. rimae
S. oralis, S. mitis, S. sanguis, S. cristatus
S. intermedius, S. constellatus,
S. anginosus, Abiotrophia adiacens
G. morbillorum, G. haemolysans
E. brachy, E. saphenum, Filifacter alocis
P. micros, Catonella morbi, V. dispar
V. parvula, Dialister pneumosintes
Sel. sputigena, S. noxia, S. infelix
13
Actinobacteria
12
18
Firmicutes
23
12
19
40
Proteobacteria
26
19
N. mucosa, H. parainfluenzae,
C. gracilis, C. concisus, C. rectus
Bacteroidetes
17
34
113
195
Prev. denticola, P. oris, P. tannerae,

T. forsythia, P. gingivalis
P. endodontalis, Capno gingivalis
C. ochracea
Clostridia
Fig. 5. Range of cultivable and as yet uncultivated species

detected in samples of subgingival plaque. The 10 bacterial phyla detected are presented to the left along with
the number of known species and novel phylotypes
detected in each phylum. On the right, example species

for each phylum are presented. Each of these species were
detected in at least four subjects. Data from (121).
145
N Clones of a
taxon detected
1
2
3
4
5
6
7
8
9
10
1119
2029
3039
4049
5099
100+
N taxa
103
52
30
11
11
10
6
11
5
3
38
11
4
5
2
4
103 taxa (34%) account for 0.04% each: total = 4.1%

52 taxa (17%) account for 0.08% each: total = 4.1%
242 taxa (79%) account for a total of 661/2522 = 26.2%
26 taxa (8.5%) account for > 50% of the microbiota
Fig. 6. Relative species abundance in subgingival plaque

samples from 31 subjects using PCR amplification of the
16S rDNA genes from plaque samples followed by cloning
and sequencing of the inserts. The figure indicates the

number of taxa that were detected once, twice, three times,
etc., in the samples from the test subjects. Data from (121).
detected accounted for > 50% of the sequenced

clones, whereas 103 taxa (43%) were detected in only
one of the 31 subjects.
The conclusion that species are not uniformly
distributed in periodontal sites may also be drawn
from other data. The 40 DNA probes utilized in Fig. 4
identified 85% of 3400 pure cultures from subgingival
plaque samples from 62 subjects. The remaining 15%
were identified by phenotypic testing or 16s rRNA
sequencing. None of these isolates was a species in
the test battery, indicating that the probes could pick
up all isolates of that species. Since, on average, we
recover about 70% of the cells enumerated by
microscopic count, the 40 DNA probes would account
for 5560% of the bacteria in subgingival biofilms.
This finding is in accord with the data from Paster
et al. (121) and supports the notion that a limited set
of species accounts for the vast majority of bacterial
cells encountered in subgingival biofilm samples.
Species abundance may be expressed in a number
of ways. Figure 7 depicts the mean counts 105 of 40
taxa in 20,247 subgingival samples from 184 periodontally healthy subjects and 592 subjects with
chronic periodontitis. The dominant species was
Actinomyces naeslundii genospecies 2. This is not
surprising given that the majority of sampled sites
exhibited shallow pocket depths. If only deep pockets
were sampled, a somewhat different picture would

emerge, as will be seen in a later section. Other prevalent species included Prevotella nigrescens, Prevotella intermedia, Veillonella parvula, T. forsythia, and
Prevotella melaninogenica.
146
Species diversity
Diversity indices are often used by ecologists to
describe species richness and species evenness in
diverse ecosystems (93). Examples of the use of some
of these indices are presented in Fig. 8. For each index,
diversity was computed at a site, averaged across sites
in a subject, and then averaged across subjects in the
periodontally healthy and chronic periodontitis
groups described above. The first three indices (Hills
N0, N1, and N2) were chosen because they are readily
interpretable in terms of actual numbers of species.
Hills N0, the number of species detected, averaged
about 22 and 24 per site for the periodontally healthy
and periodontitis subjects, respectively. The effective
number of abundant species was about the same in
both clinical groups, while the effective number of
very abundant species was higher in samples from
periodontal health than in samples from periodontitis.
Hills evenness index ranges from 0 to 1, with 1
indicating a perfectly even distribution of species
and 0 a very skewed distribution. There appeared
0.0
1.2
Counts x 105
2.5
3.8
5.0
A. naeslundii 2
P. nigrescens
P. intermedia
V. parvula
T. forsythia
P. melaninogenica
C. gingivalis
P. gingivalis
A. naeslundii 1
F. nucleatum ss nucleatum
F. nucleatum ss vincentii
A. gerencseriae
C. gracilis
N. mucosa
A. israelii
C. rectus
F. nucleatum ss polymorphum
P. micros
F. periodonticum
C. sputigena
L. buccalis
E. nodatum
T. denticola
E. corrodens
S. noxia
C. showae
A. odontolyticus
C. ochracea
E. saburreum
G. morbillorum
S. sanguis
A. actinomycetemcomitans
S. oralis
S. gordonii
S. mitis
P. acnes
S. anginosus
T. socranskii
S. intermedius
S. constellatus
Fig. 7. Bar chart of the species abundance of subgingival
taxa as determined by checkerboard DNADNA hybridization. The mean counts of 40 species in samples from 184
periodontally healthy subjects and 592 adult subjects with
chronic periodontitis are presented. The total number of
samples was 20,247 (mean 26.1 per subject). Counts of

each species were averaged within a subject and then
across subjects. The bars and whiskers represent mean
counts 105, SEM.
to be greater evenness in the samples from the

periodontally healthy sites than in the samples from
periodontitis subjects. As Ludwig & Reynolds (93)
point out, diversity indices are often used in ecology
but are difficult to interpret.
periods of snow and hot weather still another.

Habitat is also a pre-eminent factor in determining
species associations among microorganisms. Some of
the selective pressures that determine bacterial species assemblages were briefly mentioned in the
principles section and include shared nutrient or
environmental requirements, similar receptors for
initial adhesion, shared mechanisms for protection
from host and other species, and the dependence of
one species on another for colonization. Attempts to
define some of the principles of species association
have been carried out in vitro and include efforts to
define specific species pairs involved in coaggrega-
Microbial associations in subgingival biofilms

Casual examination of our macro environment
indicates that there are easily discernible specific
species associations in different habitats. Often these
associations are habitat-driven. For example, a dry
climate may select one set of plant species, a wet
climate another, and a climate that has alternating
147
Hills N0 (Number of species)
Hills N1 (Effective number of abundant species)
P < 0.05
ns
24
16
18
12
12
Hills N2 (Effective number of very abundant species)

12
P < 0.05
Evenness Index (E5)

1.00
0.75
0.50
0.25
0.00
Health
P < 0.001
Periodontitis
Fig. 8. Bar plots of four diversity indices used to compare

subgingival samples from the 184 periodontally healthy
subjects and 592 adult subjects with chronic periodontitis
presented in Fig. 7. The diversity indices were computed

(93) for each site and averaged within a subject prior to
averaging across subjects in the two groups.
tion (74, 75) as well as species interactions that may

occur in in vitro mixed culture experiments (142, 164,
180). In 1998 (156), an effort was made to define
species associations that occur in subgingival biofilms in vivo. The genesis of this approach was the
expectation that specific species associations must
occur in subgingival biofilms since they occur regularly in other ecosystems in nature. In addition, in the
early years, checkerboard DNADNA hybridization
membranes were read visually by the authors, who
came to recognize that when certain species were
detected at a site, certain other species were virtually
certain to be there as well. This notion was tested by
analysis of data from over 13,000 subgingival biofilm
samples from 185 subjects with different states of
periodontal health and disease (156). Associations
between all pairs of species were measured by various similarity coefficients and the resulting similarity
matrices subjected to cluster analysis. These analyses
supported the hypothesis that there were distinct
complexes of microorganisms in subgingival biofilms. The data were examined further using two
community ordination techniques, principal components analysis and correspondence analysis. These
analyses were valuable in that they confirmed the
complexes described by the pairwise cluster analyses
and suggested the nature of the relationships of the
complexes (communities) to each other. The publication of this paper was greeted by more enthusiasm
than was anticipated. This appeared to be in large
part because the delineation of the colored complexes provided a framework for describing and
understanding the subgingival ecosystem. The original synthesis of the cluster and community ordination analyses is presented in Fig. 9.
As will be seen in later sections, specific complexes
relate to their habitat in terms of periodontal
health disease, local clinical characteristics and the
systemic background of the host. The relationships
among species described in Socransky et al. (156)
paralleled the findings of in vitro coaggregation
studies (74, 75). Species that make up the complexes
also appear to be distributed in different regions of
the periodontal pocket gingival sulcus as determined
148
Fig. 9. Diagrammatic representation of the relationships of species within microbial complexes and between the
microbial complexes. Updated from (156) with B. forsythus changed to T. forsythia.
by in situ immunocytochemistry. Figure 10, which is

based on publications by Kigure et al. (72) and Noiri
et al. (110113), indicates regions in the subgingival
area that appear to be enriched for specific microbial
complexes.
The second component: influence of

surface on the composition of intraoral
biofilms
Comparison of microbial composition of biofilms
on teeth and soft tissues
One of the key determinants of biofilm composition is
the nature of the surface on which the biofilm develops. Nowhere is this more easily demonstrated than by
examining the composition of the biofilms that develop on the teeth and the various soft tissue surfaces of
the oral cavity. Mager et al. (98) used checkerboard
DNADNA hybridization to compare the composition
of the microbiota taken from eight different soft tissue surfaces and saliva as well as supragingival and,
separately, subgingival plaque in the same individuals.

The samples differed markedly in the proportions of
the 40 test taxa examined. For example, much higher
proportions of Actinomyces species were observed in
samples from the tooth surfaces, high proportions of
P. melaninogenica were observed in samples from
saliva and the dorsal and lateral surface of the tongue,
and high proportions of Streptococcus mitis and
S. oralis were observed in samples from the remaining
soft tissue surfaces (Fig. 11). Cluster analysis of the
samples (Fig. 12) revealed that the samples from the
dorsum and lateral surfaces of the tongue and from
the saliva were similar to each other and confirmed an
earlier notion that the source of most bacterial cells in
saliva was the tongue surface. The microbiotas of the
other soft tissue surfaces, including tongue ventral,
floor of mouth, hard palate, cheek, vestibulelip, and
attached gingiva formed a second cluster. The two
clusters formed by the soft tissue and saliva samples
were more similar to each other than to the samples
taken from supragingival and subgingival plaque,
which made up a third cluster.
149
POCKET
POCKET WALL
WALL
ROOT SURFACE
Fig. 10. Histologic section of human subgingival dental

plaque stained with toluidine blue-methylene blue. The
tooth surface is to the left and the epithelial lining of the
periodontal pocket is to the right. Bacterial plaque attached
to the tooth surface is evident towards the upper left of the
section, while a second zone of organisms can be observed

lining the periodontal pocket wall. (Courtesy of Dr. Max
Listgarten). The suspected location of species in the different complexes has been indicated on the section based
on data from Kigure et al. (72) and Noiri et al. (110113).
The findings of this study highlight the importance

of the nature of the surface to be colonized on subsequent biofilm composition. In this study, each
subject was hisher control, ruling out possible host
background differences. The saliva bulk fluid bathing the surfaces was essentially identical for all
locations except for the subgingival samples. In spite
of these identical background factors, the biofilms
differed markedly due to distinct differences in the
surfaces that became colonized. Nowhere was this
more apparent than for the tongue dorsum vs. hard
palate. These two soft tissue surfaces come in contact
with each other hundreds of times each day and yet
the microorganisms colonizing these surfaces were
radically different in terms of both abundance and
species proportions.
surfaces on the composition of hard tissue and soft

tissue biofilms. The microbiota of the edentulous
subject is not well understood because there have
been relatively few studies of the microbiota colonizing dentures or the mucous membranes or saliva in
edentulous subjects. At one age extreme, studies of
the edentulous oral cavity of infants prior to tooth
eruption suggest that anaerobic species could be
detected in the absence of teeth and that P. melaninogenica was the most frequently isolated anaerobic species, being found in 70% of infants (77).
Other common anaerobes included Fusobacterium
nucleatum, Veillonella species, and nonpigmented
Prevotella. The source of the anaerobes appeared to
be the mother since there was a correlation between
maternal salivary concentration and the infants
colonization by P. melaninogenica (78). At the other
end of the age spectrum, the microbiota of 51
edentulous subjects (mean age 74 years) with complete dentures was studied (76). Samples were taken
from the fitting surface of the denture as well as the
palate, buccal mucosa, dorsum of the tongue and
Comparison of microbial composition of biofilms

on teeth and dentures
The replacement of all of the natural teeth by full
dentures provides a direct method to assess the
possible effect of change in intraoral hard tissue
150
Supra
% DNA probe count
18 0
Sub
9
18 0
Saliva
Tongue
dorsum
18 0
Tongue Tongue
lateral
ventral
18 0
18 0
Floor of
mouth
18 0
Buccal
18 0
18 0
Hard Vestibule Attached

palate
lip
gingiva
9
18 0
18 0
18
A. naeslundii 2
A. naeslundii 1
V. parvula
N. mucosa
A. israelii
A. gerencseriae
L. buccalis
E. corrodens
S. sanguis
A. odontolyticus
E. nodatum
F. periodonticum
C. gracilis
S. mitis
S. oralis
C. gingivalis
P. intermedia
C. sputigena
E. saburreum
G. morbillorum
P. gingivalis
S. gordonii
P. micros
C. ochracea
S. noxia
P. nigrescens
P. melaninogenica
C. showae
S. anginosus
T. forsythia
C. rectus
P. acnes
S. constellatus
T. socranskii
T. denticola
S. intermedius
Fig. 11. Mean percentage DNA probe count ( SEM) for

samples from the 11 intraoral locations in 41 periodontally healthy and 39 subjects with chronic periodontitis.
Species are ordered according to their mean proportions
in supragingival plaque. Significance of differences among
sample locations was determined using the KruskalWallis test and adjusted for multiple comparisons (157). All
species were significantly different among groups at

P < 0.001 with the exception of Streptococcus constellatus
and Gemella morbillorum. The colored bars represent
species that showed particularly marked differences
among sample locations. Updated from (98) by the addition of 36 subjects.
saliva. Black pigmented Bacteroides were found in

96% of subjects, and yeasts in 49% of subjects. Of the
saliva samples, 84% yielded mutans streptococci and
92% lactobacilli. Data in the literature suggest that
certain species such as Streptococcus mutans require
hard surfaces for sustained colonization (18, 43, 91,
169), although they may be detected in dentate subjects at low levels on the soft tissues. Studies have
suggested that S. mutans essentially disappears from
the oral cavity when all the teeth are extracted and
reappears if hard surfaces are provided in the form
of full dentures (18, 43, 91, 169). Other studies
have suggested that A. actinomycetemcomitans and
P. gingivalis disappear from the oral cavity after
extraction of all the teeth and do not re-appear even
when hard surfaces such as full dentures are provided
(26). S. mutans as well as lactobacilli can be found in
the mouths of edentulous subjects wearing dentures,
suggesting that dentures provide a surface for colonization (18, 43, 169). Theilade et al. (168, 169)
examined the predominant cultivable microbiota on
dentures in patients with healthy mucosa or denture-
induced stomatitis. They found that the microbiota in

both instances was dominated by gram-positive
organisms, primarily members of the genera Streptococcus, Actinomyces, and Lactobacillus. Veillonella
species made up about 10% of the microbiota,
whereas gram-negative rods constituted < 1%.
The data from the above studies are intriguing in
that they suggest that the teeth may be essential for
colonization of species such as A. actinomycetemcomitans and P. gingivalis. Further, hard surfaces
appear essential for the colonization of S. mutans.
The data of Theilade et al. (168) suggest that the
gingival crevice as well as the fluid passing through
the gingival crevice may also be essential for the
colonization of most gram-negative rod species
including common species such as F. nucleatum,
P. intermedia, and P. nigrescens.
Thus, the findings in the literature suggest the need
for hard surfaces for the colonization of some species
and the gingival crevice fluid from gingival sulci or
periodontal pockets for the colonization of others.
This notion prompted us to compare the microbiota
151
% similarity (minimum similarity coefficient)

60
70
80
90
Subgingival
Supragingival
Cluster A
Tongue dorsum
Saliva
Tongue lateral
Cluster B
Hard palate
Tongue ventral
Buccal
Floor of mouth
Cluster C
Attached gingiva
Vestibule lip
Fig. 12. Dendrogram of a cluster analysis of the mean
species proportions from the 11 sample locations described in Fig. 11. A minimum similarity coefficient was
employed and an average unweighted linkage sort. Three

clusters were formed at >80% similarity. Cluster B was
more similar to Cluster C than Cluster A.
on dentures of individuals who were fully edentulous

and had been wearing dentures for at least 1 year with
that present in samples of supragingival plaque from
subjects who were periodontally healthy or who had
chronic periodontitis. Supragingival plaque samples
were taken from the mesial aspect of each tooth (or
denture tooth) in 28 periodontally healthy, 8 periodontitis, and 18 fully edentulous denture-wearing
subjects and individually analyzed for their content of
41 bacterial species (the standard 40 + S. mutans)
using checkerboard DNADNA hybridization. The
counts were averaged within a subject and then
across subjects in the 3 clinical groups. The mean
( 105, SEM) total DNA probe counts were 45 7,
66 13, and 52 11 in healthy, periodontitis, and
edentulous subjects, respectively. The mean microbial profiles differed quite markedly among clinical
groups (Fig. 13). Noteworthy were the lower levels of
Capnocytophaga ochracea, Capnocytophaga sputigena, Campylobacter rectus, Campylobacter showae,
T. forsythia, Neisseria mucosa, and P. melaninogenica
in samples from the subjects with dentures. These
data, although limited in the number of subjects
studied to date, support the concept that the nature of
the hard tissue surface impacts on the composition of
the biofilms that form on hard tissue surfaces.
Soft tissue and saliva samples from the same group

of subjects were also examined by checkerboard
DNADNA hybridization (Fig. 14). In general, the
mean microbial profiles at the different sample
locations were more similar between the healthy and
periodontitis subjects than the edentulous subjects.
Proportions of F. nucleatum subspecies, Eikenella
corrodens, and V. parvula were significantly lower for
most sample locations in the edentulous subjects. In
contrast, proportions of S. mitis and Streptococcus
gordonii were significantly higher at all soft tissue
sites, except the tongue dorsum and tongue lateral in
the edentulous subjects. Fusobacterium periodonticum was consistently detected in significantly higher
proportions on all soft tissue surfaces and in the
saliva of the edentulous subjects. In addition, total
DNA probe counts were higher on the soft tissues of
edentulous subjects. These data suggest that the oral
soft tissue microbiotas of edentulous subjects also
differed markedly from that observed in healthy or
periodontitis subjects and suggest that the nature of
the hard tissue surface in the oral cavity not only
impacts on the nature of colonizing species on hard
tissue surfaces, but also on the soft tissue surfaces.
One caveat to the interpretation of the findings of this
section is that the different methods used by dentate
152
Counts x 105
0.0
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. mutans
S. noxia
T. socranskii
2.3
4.6
6.9
9.2
Actinos
Purple
Yellow
Green
edentulous
health
Orange
periodontitis
**
Red
Other
Fig. 13. Profiles of mean counts of 41 taxa in supragingival plaque samples from 28 periodontally healthy,
8 chronic periodontitis, and 18 fully edentulous subjects.
Plaque samples were taken from the mesial aspect of each
tooth or denture tooth and analyzed separately for their
content of 41 species. Data for each species were averaged
within a subject and then across subjects in the three

clinical groups separately and significance of differences
among groups sought using the KruskalWallis test and
adjusted for multiple comparisons (157); *P < 0.05;
**P < 0.01; ***P < 0.001. Species were ordered according
to the complexes described by Socransky et al. (156).
and edentulous subjects to clean their teeth may

also have an impact on the colonizing microbiota.
probably facilitates person to person transfer. The

major bulk fluid in the oral cavity is saliva, which is
essential to the survival of almost all oral biofilms
with the exception of biofilms in subgingival areas or
areas within pathologic lesions such as root canal
infections or oral abscesses. Examination of the
existing literature suggests a number of intriguing,
seeming inconsistencies. For example, the total
viable counts of bacteria in saliva average about 108
per ml (13, 66, 139). The total daily amount of saliva
secreted has been variously estimated at 500 ml
(178, 179), 1000 ml (138) or 1500 ml (32, 45). Thus,
theoretically, about 1 1011 bacteria would be
The third component: influence of bulk

fluid on the composition of intraoral
biofilms
The critical role of bulk fluid saliva
Bulk fluid is critical to the survival of species in a
biofilm. This fluid provides nutrients, removes waste
products, and acts as the vehicle for transport of
bacterial cells from site to site in the oral cavity and
153

Tongue
dorsum
Saliva
% DNA probe count
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. mutans
S. noxia
T. socranskii
10
20
10
20
Tongue
lateral
0
10
20
Tongue
ventral
0
10
20
Floor of
mouth
0
10
20
Hard
palate
Buccal
0
10
20
Vestibule Attached
lip
gingiva
10
20
**
**
*
10
20
10
20
**
***
**
**
*
***
**
***
*
***
**
***
***
**
**
**
***
*
***
***
***
***
***
***
***
***
**
*
***
***
***
***
***
*
***
***
**
***
*
***
***
***
*
*
*
health
periodontitis
edentulous
Fig. 14. Profiles of mean percentage of the DNA probe

count of 41 taxa in samples from 8 soft tissue surfaces and
saliva obtained from 28 periodontally healthy, 8 chronic
periodontitis, and 18 fully edentulous subjects. Samples of
saliva were obtained by expectoration and samples from
the indicated soft tissue surfaces were obtained using a
buccal brush and analyzed separately for their content of

41 species. Significance of differences among groups for
each species was sought using the KruskalWallis test and
adjusted for multiple comparisons (157); *P < 0.05;
**P < 0.01; ***P < 0.001. Species were ordered according
to the complexes described by Socransky et al. (156).
swallowed each day. This translates to about 1 g wet

weight of bacterial cells. Where do these bacteria
come from? The average total mass of bacteria on the
teeth of a healthy subject has been estimated to be
about 16 mg, while an average value for periodontitis
subjects was about 83 mg (149). The mass and
number of organisms that colonize the soft tissues
are not known. Collins & Dawes (23) measured the
surface area of the oral cavity and found that teeth
made up about 20% of the available surface for
microbial colonization. If organisms colonized at the
same density on the soft tissues as on the teeth, then
the mass of organisms might be estimated to be four
times as high or perhaps 400 mg. Thus, one might
estimate about 500 mg of bacteria might colonize the
oral cavity. Even if the total mass were 1 g of bacteria,
this would suggest that the entire mass of organisms,
on average, would duplicate each day. Generation
times would have to be shorter if smaller masses of

bacteria colonized the oral cavity or if only a limited
segment of the microbiota was capable of replicating.
One possible explanation for the large numbers of
bacteria in saliva is that the saliva is supporting
multiplication while the bacteria are in saliva (14, 28
30, 174). This is possible but the high turnover rate of
saliva in the oral cavity makes this unlikely. It has
been estimated that the volume of saliva within the
oral cavity typically ranges from 0.77 to 1.07 ml (81).
If the flow rate were, on average, 1 ml per min, then
the turnover of saliva would be very short and
the likelihood of bacterial multiplication in saliva
explaining the numbers of bacteria observed would
be rather small.
These observations set the stage for a set of
intriguing questions. If the flow rate of saliva were
markedly diminished, what would happen to the
154
counts of bacteria in saliva, to the microbiotas that

colonize the soft tissues, and to the microbiotas that
colonize the tooth surfaces? On the one hand, saliva
might remove or limit bacteria on the hard and soft
tissues and perhaps affect microbial composition. On
the other hand, saliva may provide nutrients to surface colonizing species and provide a means of
transport from one surface to another, increasing
bacterial load. Thus, a decrease in saliva could alter
the microbial composition in both beneficial and
harmful ways. Studies of xerostomia, a common
clinical condition that affects a large proportion of
the adult, particularly senior, population, could help
to answer some of these questions. Xerostomia
occurs as a result of certain medications, radiation or
chemotherapy or as part of an autoimmune syndrome called Sjogrens syndrome. The last condition
affects, among other things, saliva production,
decreasing the mean unstimulated flow rate to values
well below 0.1 ml per min (177). This condition
provides an excellent model to ask critical biofilmrelated questions: does the composition of the
microbiota differ in Sjogrens subjects from that
observed in age-matched controls? Will the
re-development of soft tissue biofilms differ in
subjects whose saliva production is markedly
diminished? These questions are being addressed in
ongoing studies carried out in association with
Dr. Athena Papas at Tufts School of Dental Medicine.
The purpose of the first phase of investigation was to
compare the supra- and subgingival microbiotas of
Sjogrens subjects with those of periodontally healthy
and periodontitis subjects. Separate supra- and subgingival plaque samples were taken from the mesial
aspect of each tooth at baseline in 24 Sjogrens, 30
periodontally healthy, and 53 periodontitis subjects
and individually analyzed for their content of 40
bacterial species using checkerboard DNADNA
hybridization.
The mean ( 105, SEM) total DNA probe counts in
Sjogrens, health, and periodontitis were supragingivally 13 3, 44 7, and 43 4 (P < 0.001). This
suggests that saliva may foster growth of bacterial
species in supragingival biofilms or that Sjogrens
subjects were far more fastidious in their home care
than subjects with normal salivary flow. Subgingivally, mean counts were 11 1, 15 2, and 25 2,
respectively (P < 0.001). The significant difference
among groups in the subgingival samples was due to
higher mean counts in the periodontitis subjects than
in the other two groups. This suggests that the subgingival domain was less affected in the Sjogrens
subjects, possibly due to gingival crevice fluid provi-
ding the bulk fluid to the area rather than saliva. In

supragingival samples, mean counts of 30 species
(Fig. 15) and proportions of 10 species differed significantly among groups after adjusting for multiple
comparisons. In subgingival samples, mean counts of
19 species (Fig. 16) and proportions of 16 species
differed significantly among groups. The species with
the highest mean counts in both supra- and subgingival samples from Sjogrens subjects were V. parvula
and N. mucosa. Although the mean supragingival
counts of V. parvula did not differ significantly
among the three clinical groups (Fig. 15), the mean
proportions of this species did. The mean percentage
( SEM) in Sjogrens, health, and periodontitis was
17 2, 9 1, and 10 1 (P < 0.05), respectively.
N. mucosa also exhibited significantly different proportions; 14 2, 11 2, and 4 1 (P < 0.001) in
Sjogrens, health, and periodontitis, respectively. The
subgingival microbiota of Sjogrens exhibited low
counts of most species compared with periodontitis
and healthy subjects. T. forsythia, P. gingivalis,
Treponema denticola, and Treponema socranskii were
markedly higher in subjects with periodontitis than in
healthy or Sjogrens subjects. These data indicate that
there were many significant differences in the supraand subgingival microbial composition of periodontally healthy, chronic periodontitis and Sjogrens
syndrome subjects. However, differences in mean
microbial profiles among the three clinical groups for
subgingival plaque were not the same as those
observed for supragingival plaque.
The microbiota of the oral soft tissues and saliva
was compared in Sjogrens subjects and subjects with
normal salivary flow. Biofilm samples from soft tissues were taken in 24 Sjogrens subjects and 11
controls at baseline. The samples were taken using a
buccal brush from the tongue dorsum, lateral and
ventral surfaces, floor of mouth, buccal, hard palate,
vestibulelip and attached gingiva. These samples as
well as an unstimulated saliva sample were individually analyzed for their content of 41 bacterial
species using checkerboard DNADNA hybridization. Levels and percentage DNA probe counts of
each species were determined for each sampled site
and averaged across subjects in the two clinical
groups.
There were significantly lower mean total DNA
probe counts ( 105, SEM) for Sjogrens subjects
compared with controls (Fig. 17) in the samples from
the tongue dorsum (47 10 vs. 98 22), buccal
(6 1 vs. 16 4), and hard palate (8 2 vs. 33 15).
For these locations, species that were significantly
elevated at multiple sample locations in the control
155
Counts x 105 0.0
1.3
A. gerencseriae***
A. israelii***
A. naeslundii 1***
A. naeslundii 2***
A. odontolyticus***
V. parvula
S. gordonii**
S. intermedius
S. mitis***
S. oralis***
S. sanguis***
A. actinomycetemcomitans***
C. gingivalis***
C. ochracea***
C. sputigena***
E. corrodens***
C. gracilis
C. rectus ***
C. showae***
E. nodatum
F. nucleatum ss nucleatum***
F. nucleatum ss vincentii***
F. periodonticum***
P. micros
P. intermedia***
P. nigrescens***
S. constellatus*
T. forsythia***
P. gingivalis***
T. denticola**
E. saburreum**
G. morbillorum**
L. buccalis
N. mucosa*
P. acnes***
P. melaninogenica
S. anginosus**
S. noxia
T. socranskii***
SUPRAGINGIVAL
2.5
3.8
5.1
Actinos
Purple
Yellow
Periodontitis
Health
Sjogrens
Green
Orange
Red
Other
Fig. 15. Profiles of mean counts of 40 taxa in supragingival plaque samples from 28 periodontally healthy,
53 chronic periodontitis, and 24 Sjogrens subjects. Plaque
samples were taken from the mesial aspect of each tooth
and analyzed separately for their content of 40 species.
Data for each species were averaged within a subject and
then across subjects in the three clinical groups separately

and significance of differences among groups sought
using the KruskalWallis test and adjusted for multiple
comparisons (157); *P < 0.05; **P < 0.01; ***P < 0.001.
Species were ordered according to the complexes described by Socransky et al. (156).
subjects were S. oralis, E. corrodens, N. mucosa,

Propionibacterium acnes, and P. melaninogenica
(Fig. 18). Using cluster analysis (Fig. 19), the mean
microbial profiles for Sjogrens and control subjects
clustered separately. Further, in each clinical group,
two clusters were formed consisting usually of saliva
and tongue dorsum samples vs. the remaining surfaces. These data indicate that microbial species on
the soft tissues and in saliva of Sjogrens subjects
differed in quantity and proportions from species
detected in control subjects and suggest that the
decreased levels of saliva in Sjogrens syndrome
subjects may have affected the amount and nature of

the species exposed to this bulk fluid.
156
The critical role of bulk fluid gingival crevice fluid

The major bulk fluid that affects most of the exposed
surfaces of the oral cavity is saliva. A second locally,
and possibly generally, important bulk fluid is gingival crevice fluid, which emanates from the sulcus or
periodontal pocket in dentate subjects. Some studies
suggest that this fluid may be critical for sustained
colonization of certain taxa (26). It has also been
suggested that the inflammatory state of the gingival
Counts x
105
0.0
0.6
A. gerencseriae***
A. israelii***
A. naeslundii 1***
A. naeslundii 2***
A. odontolyticus***
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
A. actinomycetemcomitans*
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus ***
C. showae
E. nodatum*
F. nucleatum ss nucleatum***
F. nucleatum ss vincentii***
F. periodonticum***
P. micros**
P. intermedia*
P. nigrescens***
S. constellatus
T. forsythia***
P. gingivalis***
T. denticola***
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. noxia***
T. socranskii***
SUBGINGIVAL
1.1
1.7
2.3
Actinos
Purple
Yellow
Periodontitis
Health
Sjogrens
Green
Orange
Red
Other
Fig. 16. Profiles of mean counts of 40 taxa in subgingival plaque samples from 28 periodontally healthy, 53 chronic
periodontitis, and 24 Sjogrens subjects. The methodology and statistical analysis are as described for Fig. 15.
sulcus or periodontal pocket is important to the rate

and perhaps nature of microbial colonization at or
below the gingival margin (54, 67, 129, 131, 133, 146).
Sites that exhibit natural gingivitis (131) or experimentally induced gingivitis (67, 129, 133) exhibit far
more rapid plaque re-growth than periodontally
healthy sites. The explanation for this has, at least in
part, been a greater flow rate of the bulk fluid, gingival crevice fluid. The flow rate of gingival crevice
fluid is related to surrogate measures such as the
Gingival Index or other measures of gingival inflammation (115, 163, 171).
It was shown above that the composition of the
biofilms present on natural teeth differs from that
observed in samples from dentures. Some of the
differences may have been due to the nature of the
surface present for initial colonization. Some, however, may have been due to the availability of gingival
crevice fluid in the dentate but not the edentulous
subjects. It has been suggested that A. actinomycetemcomitans and P. gingivalis disappear from the
oral cavity after extraction of all the teeth and do not
re-appear even when hard surfaces such as full dentures are provided (26). Is this true? Or is this finding
due to the less sensitive cultural techniques that were
used? This issue is of major consequence because it
has been recognized for some time that A. actinomycetemcomitans is a common colonizer of the soft
tissues and supragingival plaque (39, 44, 107109,
160). However, if the removal of the natural teeth
leads to the eradication of this species as well as
P. gingivalis, then this strongly implicates gingival
157
125.2
P < 0.05
Counts x 105
93.9
Control (n = 10)
Sjogrens (n = 24)
62.6
P = 0.07
P < 0.05
31.3
P < 0.05
0.0
Saliva
Dorsum
Tongue
Floor
Hard Vestibule Attached
Lateral Ventral of mouth Buccal palate
lip
gingiva
Fig. 17. Bar chart of the mean total DNA probe counts in
24 Sjogrens and 10 matched control subjects in saliva and
at 8 intraoral soft tissue locations. Saliva samples and
microbial samples taken from the soft tissue surfaces were
individually analyzed for their content of 40 bacterial
species. The total DNA probe counts were computed for
each subject for each sample site and then averaged

across subjects in the two groups for each sample location
separately. Significance of differences in total counts
between Sjogrens and control subjects were determined
using the MannWhitney test.
crevice fluid or the periodontal pocket environment

as essential to sustained colonization by these
consensus periodontal pathogens. In the studies
of edentulous subjects described above, both
P. gingivalis and A. actinomycetemcomitans as well
as T. forsythia were detected on the dentures and soft
tissues of some but not all subjects. Since this was at
odds with existing literature, we examined the composition of split microbial samples from the dorsum
of the tongue and the denture of 10 fully edentulous
subjects using checkerboard DNADNA hybridization, conventional culture techniques, and PCR.
P. gingivalis and T. forsythia were detected by
hybridization in nine and eight samples each from
the dentures. However, the species were not detected
in pure culture on enriched media. PCR using primers directed to the 16S rRNA genes (5) did detect the
species in aliquots of the same samples, suggesting
that culture was less sensitive for the detection of low
numbers of these species in biofilm samples than the
molecular methods. The data indicate that P. gingivalis, A. actinomycetemcomitans, and T. forsythia can
be detected in edentulous subjects 1 year or longer

after all teeth have been extracted.
158
Comparison of supragingival and

subgingival biofilm composition
Three components are described above as making up
a biofilm; the surface to be colonized, the colonizing
microbiota, and the bulk fluid. These components
differ for supra- and subgingival biofilms and impact
on the microbial composition of biofilm samples
from the two locations. Figures 20 and 21 compare
the mean counts and mean proportions of species in
supragingival and subgingival biofilms, respectively.
Because periodontal disease status impacts so
markedly on biofilm composition (to be discussed
below), data from 50 periodontally healthy subjects
(left panels) and 89 periodontitis subjects (right
panels) are presented separately. The mean counts of
most species are significantly higher in supragingival
than in subgingival biofilms of periodontally healthy
subjects (Fig. 20, left panel). This should come as no
Saliva
Dorsum*
Tongue
Lateral
Ventral
Floor
of mouth
Buccal*
Hard*
palate
Vestibule Attached
lip
gingiva
Counts x 105 0.0 2.7 5.4 0.0 5.4 10.70.0 3.1 6.1 0.0 0.7 1.3 0.0 0.9 1.8 0.0 1.2 2.5 0.0 1.7 3.5 0.0 1.1 2.3 0.0 3.6 7.1
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. mutans
S. noxia
T. socranskii
Actinos
Purple
Yellow
Green
Orange
Red
Other
Control
Sjogrens
Fig. 18. Mean microbial profiles of saliva and 8 oral soft

tissue surfaces in 24 Sjogrens and 10 matched control
subjects. The samples were collected and analyzed as
described in Fig. 17. Significance of differences in bacterial counts between Sjogrens and control subjects was
determined for each sample location using the Mann

Whitney test. Significant differences between Sjogrens
and control subjects were seen in the microbial profiles of
the tongue dorsum, buccal mucosa and hard palate.
surprise to anyone who has ever treated a periodontally healthy subject. The major difference appears to
be in much higher counts of Actinomyces species and
members of the purple, yellow, green, and other
complexes. The proportions of species were not
markedly different from supragingival to subgingival
plaque in periodontally healthy subjects (Fig. 21, left
panel). There tended to be somewhat higher proportions of Actinomyces and Streptococcus sanguis in
supragingival sites, whereas orange complex species
were in somewhat higher proportions in subgingival
sites.
The mean counts of supragingival and subgingival
plaque were higher in subjects with periodontitis
(Fig. 20, right panel) than in periodontally healthy
subjects. Comparison of the left and right panels of
Fig. 20 indicates that there was a marked increase in
many taxa in the subgingival biofilms of periodontitis
subjects; particularly in orange and red complex species. There was also an increase in many of the species
in supragingival plaque of the periodontitis subjects
(Fig. 20, right panel). There were many more significant differences between the proportions of bacterial
species in supragingival compared with subgingival
biofilms in the subjects with periodontitis (Fig. 21,

right panel) than in the periodontally healthy subjects.
There were increased proportions of the Actinomyces
species and green complex species along with
N. mucosa in supragingival biofilms, and significantly
higher proportions of members of the orange complex
and all red complex species in subgingival biofilms.
The generally higher counts of many species in
supragingival than in subgingival biofilm samples,
particularly in periodontally healthy subjects, probably reflects, in large part, the space available for
colonization, i.e. a physical barrier for colonization.
The gingival sulcus in periodontally healthy sites
provides little space for the habitation of large numbers of microorganisms. And while the periodontal
pocket in diseased subjects provides a greater space for
microbial colonization, counts in the supragingival
area are still somewhat higher than in the adjacent
subgingival site for most species. This varied from
subject to subject in the periodontitis group. Some
subjects showed far higher counts in supra- than in
subgingival samples, while others exhibited higher
counts in the subgingival samples. This may have
reflected individual oral hygiene practices.
159
% similarity (minimum similarity coefficient)

60
70
80
90
Buccal
Tongue ventral
Floor of mouth
Attached gingiva
Vestibule/lip
Attached gingiva
Vestibule/lip
Floor of mouth
Tongue ventral
Hard palate
Buccal
Tongue lateral
Hard palate
Tongue lateral
Tongue dorsum
Saliva
Tongue dorsum
Saliva
Control
Sjogrens
Control
Sjogrens
Fig. 19. Dendrogram of a cluster analysis of the mean

species proportions from saliva and 8 oral soft tissue
surfaces in 24 Sjogrens and 10 matched control subjects.
A minimum similarity coefficient was employed and an
average unweighted linkage sort. Four clusters were

formed at > 70% similarity. Two clusters consisted of
Sjogrens subjects and two of the control subjects.
The differences in the microbial composition of the

supra- vs. subgingival ecosystem so strongly demonstrated in the periodontitis subjects is probably
due to multiple factors. The supragingival biofilm
presents a single surface for colonization, the tooth,
whereas the subgingival area provides two surfaces,
the tooth and the epithelium lining the gingival sulcus or periodontal pocket. Indeed, the periodontal
pocket or gingival sulcus appears to be unique in the
oral cavity in that there appears to be two biofilms in
a single anatomic space. The anatomy of this area
also permits the establishment of a third zone within
the pocket, the loosely adherent plaque zone with
less intracellular matrix (86). This zone occurs
between the biofilm attached to the tooth and the
biofilm attached to the epithelium in deeper periodontal pockets. How tightly organisms in this zone
are attached to either biofilm is not clear, but its
existence is possible because the organisms in this
area are surrounded by confining tissues on all sides
except the orifice of the pocket. Without this physical
confinement, weakly adherent species would prob-
ably be washed away from colonized surfaces. A second major difference between the supra- and subgingival habitats is the nature of the bathing bulk
fluid; for supragingival biofilms this is saliva, and for
subgingival biofilms, gingival crevice fluid. The composition of the gingival crevice fluid differs from that
of saliva and the composition also differs from periodontal health to disease. These differences in composition can markedly affect the nature of species that
colonize this area. For example, species of spirochetes
are very much favored by the gingival crevice fluid
emanating from periodontal disease sites (41).
160
Development of intraoral biofilms

Biofilm development the earlier studies
Given the critical role that the microorganisms in
biofilms play in the etiology of dental diseases, it is
astonishing that the in vivo microbial changes that
occur in the development of these biofilms are not
HEALTH
Counts x
105
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. noxia
T. socranskii
PERIODONTITIS
9
12
***
***
***
12
***
Actinos
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
*
Purple
Yellow
***
***
**
**
***
***
***
***
***
Green
***
*
*
***
*
**
***
*
**
*
***
Red
***
***
***
***
***
***
***
*
**
***
Orange
***
Supra
Sub
***
**
***
Other
***
Fig. 20. Profiles of the mean counts of 40 taxa in supragingival and, separately, subgingival plaque samples from
50 periodontally healthy subjects (left panel) and 89
chronic periodontitis subjects (right panel). Supragingival
plaque samples and, separately, subgingival plaque samples were taken from the mesial aspect of each tooth and
individually analyzed for their content of 40 species using
checkerboard DNADNA hybridization. The supragingival
and subgingival counts of each species were averaged
separately within a subject and then averaged across

subjects for the two clinical groups and two sample locations. The species were ordered according to the complexes described in (156). Significance of differences in
species counts between supragingival and subgingival
samples was determined using the Wilcoxon signed ranks
test and adjusted for multiple comparisons (157):
*P < 0.05; **P < 0.01; ***P < 0.001.
known in exquisite detail. Elaborate scenarios of

plaque development have been laid out, based on
light or electron microscopic observation (86, 87, 89),
in vitro adhesion and coaggregation models (35, 48
50, 74, 75, 100, 147, 150, 165, 166), and in vitro continuous culture studies (142, 164, 180). From these
studies and others detailed in (155), the putative
steps in the development of intraoral biofilms have
been postulated as outlined in Fig. 22. However, virtually no studies have comprehensively examined
in vivo the microbial shifts that occur during supraor subgingival plaque development and no published
studies have examined changes in soft tissue biofilm
composition over time.
Ritz (140) described the changes that occurred in

plaque that formed on the labial surfaces of the six
maxillary and six mandibular anterior teeth. He used
selective media to enumerate seven genera of
organisms streptococci, Actinomyces, corynebacteria, Neisseria, fusobacteria, Veillonella, and Nocardia
in two pooled samples from each of six adult subjects
at 1, 3, 5, 7, and 9 days. Streptococci were predominant at 1 day, constituting an average of 46% of the
colonies detected. Neisseria (9%) and Nocardia (6%)
were also high in mean proportions at 1 day but decreased in counts and proportions over time (2% and
0.1%, respectively, at 9 days). Actinomyces were initially low in proportion (0.2%) but rose to 23% of the
161
HEALTH
% DNA probe count 0
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. noxia
T. socranskii
PERIODONTITIS
12
12
**
*
16
Actinos
*
**
Purple
Yellow
***
**
***
Green
***
**
Orange
***
*
**
***
***
***
*
Red
**
**
Supra
Sub
Fig. 21. Profiles of the mean percentage of the DNA count

of 40 taxa in supragingival and separately subgingival
plaque samples from 50 periodontally healthy subjects
Lateral spread
Other
**
and 89 chronic periodontitis subjects. The methodology

and statistical analysis were as described in Fig. 20.
Vertical growth
water channels
bulk fluid
Tooth surface
16
Attachment
Coaggregation
glycocalyx
Spread
Fig. 22. Diagrammatic representation of the events thought to occur during the development of dental biofilms. These
stages are discussed in (155).
162
microbiota by 9 days. Ritz (140) felt that there was

microbial succession in plaque development with
aerobic or facultative species reducing the environment for the subsequent growth of anaerobic species.
The study was a classic in its time, but by todays
standards suffered from the fact that few subjects and
samples were evaluated, that the test organisms were
not speciated, and that the anaerobic culture techniques employed were flawed due to the lack of H2 in
the anaerobic gas mixture.
Socransky et al. (161) used predominant cultivable
microbiota techniques to study shifts in the microbial
populations that occurred in supragingival plaque
forming on the buccal surface of a single tooth in one
subject. The data indicated that few shifts occurred in
microbial composition from 5 min to 8 h. There was a
marked increase in total counts and counts of specific
species that occurred at 1 day but this leveled off from
2 to 16 days. Actinomyces species were high in proportion from 5 min to 8 h but declined in proportions
to 1 day, increased in proportions from 1 to 2 days,
leveling off by 16 days. S. sanguis was detected at all
time points, increased in proportion at 1 day and
declined thereafter. This study speciated organisms to
the level possible at that time, but was limited in that
only one sample site in one subject was studied.
The most comprehensive microbiological assessment of plaque development over time in the human
was carried out by Zee et al. (188). In that study, a
single plaque sample was taken from each of five
rapid plaque-forming subjects and six slow plaqueforming subjects at days 1, 3, 7, and 14. Samples were
anaerobically dispersed, diluted and plated, and 20
30 colonies identified per subject. Gram-positive
bacteria were the predominant cultivable species in
both clinical groups, but gram-negative species
increased in proportion more rapidly in the rapid
plaque formers. At 14 days, the rapid plaque formers
had a mean of 38% gram-negative rods compared
with 17% in the 14-day samples from the slow plaque formers. The majority of cultivable gram-negative rods were in the genera Fusobacterium and
Capnocytophaga. A striking finding in Zee et al.s
study was the decrease in the proportion of grampositive cocci from 5060% at day 1 to <15% at day
14. This decrease was accompanied by an increase in
the proportion of Actinomyces species and gramnegative rods. A similar study was performed in
monkeys by Radford et al. (130). The labial surfaces
of the central incisors of 15 monkeys were cleaned
and plaque samples were then taken at 0.5, 1, 2, 4, 7,
14, and 28 days. They found a high proportion of
Streptococcus species at 1 day (35%) which fell to 7%
at day 7. The Actinomyces increased throughout the

period of plaque formation and constituted 15% of
the total colony forming units at 28 days.
Supragingival biofilm development

The very early stages of supragingival plaque development on buccallabial surfaces in 15 periodontally
healthy subjects were studied by Li et al. (84). A saliva
sample was collected by expectoration prior to
cleaning the tooth surfaces with pumice. Pooled
samples of supragingival plaque were taken 0, 2, 4,
and 6 h after cleaning using a PVDF membrane. After
each sampling, the teeth were re-cleaned and samples
were allowed to form for the next time period. The
counts and proportions of 40 bacterial species were
determined using checkerboard DNADNA hybridization. The data indicated that the distribution of
species in saliva was different from that observed in
the plaque samples from the same subjects, indicating the selectivity of the initial adhesion process
(Fig. 23). Actinomyces species were observed to
increase from 0 to 2 h but remained essentially
constant to 6 h. The major increases that were
observed were for S. mitis and S. oralis, which
increased markedly up to 6 h. Other species remained
at negligible or low levels during this time period.
A second study of supragingival biofilm regrowth for
a longer period of time also used molecular techniques (134). The authors demonstrated that 4-day
growth of plaque in the absence of home care was
quite limited in 10 subjects who had had a preparatory period during which the supragingival plaque and
gingival inflammation was brought to minimal levels
by professional and self-performed hygiene measures.
In the absence of gingival inflammation, the microbial
shifts in these subjects were also minimal.
Another study was initiated at The Forsyth Institute
to compare early microbial changes in supragingival
biofilm formation in periodontally healthy, periodontitis and edentulous subjects. Supragingival
plaque samples were taken from the mesial aspect of
each tooth (or denture tooth) in 30 periodontally
healthy, 8 periodontitis, and 18 denture-wearing
subjects, at entry, and individually analyzed for their
content of 41 bacterial species using checkerboard
DNADNA hybridization. The teeth (or dentures) were
cleaned and immediately re-sampled to provide a 0
time baseline. Subjects refrained from oral hygiene for
7 days. Plaque samples were taken from seven teeth in
randomly selected quadrants at 1, 2, 4, and 7 days and
analyzed by checkerboard DNADNA hybridization.
Counts of each species were determined for each
163
Counts x 105
0.0
1.2
2.4
3.6
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. noxia
T. socranskii
4.8
Actinomyces
Purple
Yellow
Green
Orange
Red
Other
Biofilm samples
Saliva 0 hr
0 hr
2 hr
4 hr
6 hr
Fig. 23. Microbial profiles of the mean counts ( 105) of

40 taxa in saliva samples and plaque biofilm samples
pooled from at least 20 buccal surfaces immediately
postcleaning (0), 2, 4, and 6 h in 15 subjects. Samples were
analyzed for their content of 40 bacterial species using
checkerboard DNADNA hybridization. Counts of individual species were computed in each subject and then
averaged across subjects for each time point. The species
are ordered according to the complexes described by
Socransky et al. (156).
sampled site and averaged in each subject at each time

point.
The mean ( 105, SEM) total DNA probe counts
were 45 7, 66 12, and 52 11 on entry and 6 1,
9 4, and 6 1 immediately after cleaning in healthy,
periodontitis and edentulous subjects, respectively
(Fig. 24). Total counts in healthy and periodontitis
subjects exceeded baseline values (61 11 and
64 13, respectively) at 2 days, but took 4 days in
edentulous subjects (57 18). Baseline mean counts
of most species were highest in periodontitis and
lowest in edentulous subjects (Fig. 24). Counts of
streptococci, A. actinomycetemcomitans, Peptostreptococcus micros, E. corrodens, and V. parvula
returned to baseline levels by 2 days (Fig. 25). The
remaining species returned to baseline levels by
47 days. The streptococci showed a tendency to
plateau between 2 and 7 days. The pattern of supragingival re-colonization in periodontitis and health
was virtually identical and more rapid than that
observed in edentulous subjects. However, individual

species differed in the rate and maximum level of
re-colonization achieved during 7 days of no home
care.
Two points about home care emerged from Fig. 24
and 25. First, home care is of benefit to the individual,
since the total counts of bacteria in supragingival
plaque samples were markedly increased after 7 days
of no home care compared with precleaning (entry)
levels. Second, the fact that professional cleaning
markedly lowered mean total counts from the precleaning sampling to the postcleaning baseline sampling indicates that there is a lot of room for improvement in self-performed home care procedures.
164
Subgingival biofilm development

Microbial changes that occurred in subgingival biofilm formation from baseline to 7 days were compared in the periodontally healthy and periodontitis
Supragingival
Subgingival
140
Counts x 105
105
70
35
Pre Post 1
Cleaning
4
Days
Health
Pre Post 1
Cleaning
Periodontitis
4
Days
Denture
Fig. 24. Mean total DNA probe counts ( 105, SEM) of

plaque samples taken prior to, immediately postcleaning,
and after 1, 2, 4, and 7 days of no oral hygiene in subjects
who were periodontally healthy, had periodontitis or wore

full dentures. The dashed horizontal lines are provided to
indicate the precleaning levels for each clinical group.
subjects described above. The mean ( 105, SEM)

total DNA probe counts were 16 3 and 32 10 on
entry and 5 1 and 4 1 immediately postcleaning
in healthy and periodontitis subjects, respectively
(Fig. 24). At 2 days, total counts in healthy and periodontitis subjects exceeded baseline values (22 6,
56 31). There were striking differences between
health and periodontitis in the patterns of re-colonization (Fig. 26). In periodontitis subjects, counts of
most species increased rapidly to well above baseline
values by 2 days and 17 species, including the Actinomyces and Streptococcus, decreased to about
baseline levels by 7 days. For other species, the
counts plateaued or increased. Some species did
not reach baseline levels by 7 days, including
C. gracilis, Eubacterium nodatum, P. gingivalis, and
T. denticola. For healthy subjects, the counts of most
species increased slowly over time, reaching or
exceeding baseline values by 7 days. These data
indicate that the kinetics of subgingival plaque
re-development in subjects with periodontitis or
periodontal health differs markedly, at least in the
absence of oral hygiene procedures.
As one examines the kinetics of hard tissue associated biofilm re-development, one is impressed
firstly by the speed of this process. In the absence of

oral hygiene, re-growth as measured by total counts
appeared to be achieved on average in a 24-day
period for the three clinical groups. However, it must
be stressed that there was great variability in the rate
of biofilm re-development from subject to subject.
This has been recognized for years from clinical
observation and from studies that quantified plaque
re-growth (149). The reason for these subjectto-subject differences is not known. In an earlier
section, the contribution of gingival inflammation
and increased gingival crevice fluid flow was
described. However, it may not be the total answer.
Differences in the rate of biofilm formation may be
observed in subjects or at periodontal sites with
comparable levels of clinical gingival inflammation.
Differences are also observed in the rate of biofilm
formation in subjects or sites where gingival inflammation is not clinically evident. Since gingival
inflammation only partially explains differences in
the rate of biofilm formation, there is a gap in our
knowledge of the ecologic factors that foster or limit
biofilm development in different individuals.
The data of this section support the notion of
microbial succession discussed in the principles
165
Health
Periodontitis
Denture
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
7
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. mutans
S. noxia
T. socranskii
2 4
Pre 0 1
Days
Counts x
14.0
10.5
7.0
3.5
0.0
5
10
Fig. 25. Mean counts ( 105) of 41 taxa in supragingival

who were periodontally healthy, had chronic periodontitis, or were wearing full dentures. Each slice represents
the mean counts of an individual species at the various

time points. The left edge of the slice provides the mean
count precleaning. The rapid decline to its right represents the immediate postcleaning mean values.
section of this paper in that species appeared to

multiply in waves (Fig. 27). For example, in the
supragingival plaque samples of periodontally healthy
subjects, S. oralis had reached its precleaning level by
1 day and peaked by 2 days. E. corrodens had exceeded its precleaning value by 2 days and plateaued by
4 days. By contrast, it took 47 days for A. naeslundii
genospecies 2 to reach precleaning levels. This species
and C. showae exhibited a slower rate of growth initially and appeared to be continuing to increase at the
7-day termination of the study. These data are in
accord with patterns observed by culture (161, 188).
In those studies, supragingival biofilm development
in the periodontitis subjects showed similar waves of
succession. S. oralis and E. corrodens had peaked well
above their precleaning levels by 24 days while
A. naeslundii genospecies 2 and C. showae reached
precleaning levels between 4 and 7 days and appeared
to be continuing to increase at 7 days.
Microbial succession could also be observed in
samples of subgingival plaque from periodontally
healthy and periodontitis subjects (Fig. 27). However,

there were astonishing differences in the pattern of
re-growth in samples from these clinically different
habitats. In samples from periodontally healthy
subjects, there was a similar pattern to that observed
in supragingival samples in that counts of S. oralis
and E. corrodens increased to precleaning levels by
days 12 and more or less plateaued, whereas counts
of A. naeslundii genospecies 2 and C. showae
increased more slowly and exceeded precleaning
levels only by 47 days. In sharp contrast, in the
subgingival samples from periodontitis subjects,
there was very rapid increase of A. naeslundii genospecies 2, which peaked at 2 days and declined at 4
and 7 days. The rapid increase in this species was
accompanied by a rapid increase in S. oralis and
E. corrodens, which also decreased in mean counts
after 2 days. C. showae showed a slow increase in
growth reaching precleaning levels by 4 days. The
reason for this pattern of explosive subgingival growth
of certain species followed by a decline is unknown.
166
Health
Periodontitis
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. mutans
S. noxia
T. socranskii
2 4
Pre 0 1
Days
Fig. 26. Mean counts ( 105) of 41 taxa in subgingival

who were periodontally healthy or had chronic periodontitis. Each slice represents the mean counts of an
Relation of periodontal disease

status to subgingival biofilm
composition
Microbial composition of biofilms in
periodontal health and disease
For over 100 years, each generation of oral microbiologists has come to the same conclusion; that the
subgingival microbiota of periodontally healthy subjects differs from that found in subjects with periodontitis. This conclusion was drawn initially from
light microscopy (88) and later from cultural microbiology (for review, see 63), electron microscopy (86),
antibody-based techniques (33, 185) and molecular
techniques (73). About a half century ago, Ted
Rosebury, the pre-eminent oral microbiologist of his
6.6
5.0
3.3
1.7
0.0
Counts x 105
individual species at the various time points. The left edge

of the slice provides the mean count precleaning. The
rapid decline to its right represents the immediate postcleaning mean values.
era, wondered (in conversation with the old author),

whether everybody had everything (all species), and
the difference between health and disease was simply
in the amount. This question could not be clearly
answered by the techniques available at that time,
but can be partially answered today. Figure 28 provides mean microbial profiles of subgingival samples
taken from 184 subjects who were periodontally
healthy and 592 subjects with chronic periodontitis.
The species are arranged according to the complexes
described earlier. The Figure indicates that, on average, subgingival counts are higher in the subjects
with periodontitis than in the subjects exhibiting
periodontal health and that the major differences
between health and disease occur primarily among
the species of the red and orange complexes. Indeed,
11 of 12 species in the orange complex and all three
members of the red complex were significantly
167
Health
Periodontitis
Supragingival
Counts x 105
A. naeslundii 2
4
4
S. oralis
Subgingival
Counts x 105
E. corrodens
2
C. showae
4
Pre Post 1
Cleaning
Days
Pre Post 1
Cleaning
Days
Fig. 27. Change in mean counts ( 105) of four species in

supra- and subgingival plaque samples from precleaning
to immediately postcleaning, and after 1, 2, 4, and 7 days
of no oral hygiene in subjects who were periodontally

healthy or had chronic periodontitis.
elevated in the subjects with periodontitis even after

adjusting for multiple comparisons. These data are in
accord with studies in the literature that have used
PCR to examine frequency of detection in health and
disease (5, 22, 55, 73, 80, 83, 99, 167), real time PCR
(69, 95), culture (for review, see 63), DNA probes (1),
and antibody-based techniques (20, 33, 53, 151, 185).
At this point, there can be little doubt that certain
species such as P. gingivalis, T. forsythia, and
T. denticola can be detected more frequently, in
higher proportions and in higher numbers, in subjects with periodontitis than in periodontally healthy
subjects. Other species, including uncultivable species, have also been suggested to be more frequently
detected in disease than in health using PCR techniques (80).
The difference in the composition of the subgingival microbiota between health and disease is
instructive from an ecologic point of view. While the
disease was initiated by the colonizing species, it is
not clear whether the initial steps were brought about
by some change in one or more species in a sub-
gingival site or by some change in the habitat (host),

either locally or systemically. Some of the changes in
the host induced by the colonizing species in the
early stage of periodontitis might be in the local
inflammatory status and some might lead to net loss
of periodontal tissue. In either event, an alteration
was made in the habitat (host tissue) which then
affected the composition and metabolic activities of
the colonizing microbiota. These back and forth
modifications of host and microbiota eventually led
to a new equilibrium, a new climax community,
which in turn might result in an uneasy hostparasite
equilibrium for a prolonged period of time. It is this
new climax community that we sample in the subject
with periodontitis. It did not achieve this new
microbial composition overnight. The sampled climax community might be many years and myriads of
back and forth iterations between host and parasites
from the climax community that was initially present
when the site was periodontally healthy. To change
this climax community from that adapted to the
disease state back to that present in the original
168
Counts x 105
0.0
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. noxia
T. socranskii
1.2
2.4
3.6
4.8
***
***
***
***
***
***
**
***
***
***
**
***
***
**
***
***
***
*
***
***
***
***
Fig. 28. Microbial profiles of the mean counts (105) of 40

microbial taxa in subgingival plaque samples taken from
184 periodontally healthy and 592 subjects with chronic
periodontitis at baseline. The profiles represent the mean
counts derived by averaging the counts of each species
within a subject and then across subjects for both clinical
groups. The species are ordered and color coded accord-
ing to the microbial complexes described in (156). The

darker shade of each color represents the periodontitis
subjects, while the lighter shade represents the periodontally healthy subjects. Significance of difference for
each species between groups was determined using the
MannWhitney test and adjusted for multiple comparisons (157): *P < 0.05; **P < 0.01; ***P < 0.001.
healthy situation might require more than a few wellplaced strokes with a curette, as discussed elsewhere
(65).
In the above section (and throughout this manuscript) mean values have been used to describe the
microbial communities in various habitats. Mean
values, while helpful in making incredibly complex
data understandable, can be somewhat misleading.
They fail to reflect the subject to subject variability in
both the diseased and healthy subject groups. They
also fail to represent the transition states from health
to disease. Despite these limitations, it is clear that
periodontal disease status has a major impact on the
composition of the subgingival microbiota and that,
on average, disease status affects certain species,
particularly members of the red and orange complexes, more than others.
Some of the changes that may occur as an individual progresses from periodontal health to periodontal disease may be inferred by examining mean
microbial profiles in subjects with different severities
of periodontitis. The 592 subjects with chronic periodontitis in Fig. 28 were divided into subsets at the
quartile values of mean baseline full-mouth pocket
depth (Fig. 29). There is a striking change in the
shape of the mean microbial profiles with increasing
disease severity. This shift is particularly marked for
the red complex species, which increase with
increasing mean pocket depth, and to some extent,
for some of the orange complex species. The change
in mean microbial profile may be related directly to
the increased numbers of deep periodontal pockets
in the most diseased groups, since pocket depth at a
site relates so strongly to the composition of the
169
Counts x 105
0.0
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. noxia
T. socranskii
1.4
2.8
4.2
5.6
Actinos
***
Purple
*
Yellow
**
***
*
Mean full mouth PD (mm)
***
Green
***
< 2.90
**
2.91 3.96
*
Orange
> 3.96
***
***
**
**
***
***
*** Red
Other
***
*
Fig. 29. Microbial profiles of the mean counts ( 105) of

40 microbial taxa in subgingival plaque samples taken
from the 592 subjects with chronic periodontitis in Fig. 28.
Subjects were divided into subsets according to mean fullmouth baseline pocket depth at the quartile values of 2.90
and 3.96 mm. The profiles represent the mean counts
derived by averaging the counts of each species within a
subject and then across subjects for the three clinical

groups. The species are ordered according to the microbial complexes described in (156). Significance of differences for each species among groups was determined
using the KruskalWallis test and adjusted for multiple
comparisons (157): *P < 0.05; **P < 0.01; ***P < 0.001.
subgingival microbiota, as discussed in the next

section.
sons for the relationship of increased pocket depth

with increased levels of red and orange complex
species may be suggested. Deeper pockets have a
greater epithelial surface area to which red complex
species such as P. gingivalis and T. denticola may
attach (72). The zone of loosely adherent bacteria
which appears to contain large proportions of orange
complex species (113) is increased in deep pockets
relative to shallow pockets. In addition, local factors
may limit the growth of the tooth-associated species
while promoting the growth of loosely adherent or
epithelial-associated bacteria. For example, availability of fermentable carbohydrate might limit the
growth of saccharolytic bacteria in the tooth-associated biofilm, while a relative abundance of non carbohydrate energy sources such as hydrogen, formate,
acid end products, and protein degradation products
might sustain better growth of some of the asaccharolytic species in the orange and red complexes.
The presence of gingival inflammation at a site also
markedly affects the composition of the microbiota at
Relationship of clinical parameters at a

periodontal site to composition of the
subgingival microbiota
Arguably the most important factor influencing the
subgingival microbiota is the clinical status of the
adjacent periodontal tissues. Two factors appear to
be critical; the inflammatory status of the pocket and
the periodontal pocket or gingival sulcus depth. The
relationship of these factors to microbial composition
has been recognized for quite some time (157). The
relationship between pocket depth at a site and
the counts of specific species is shown in Fig. 30. The
data indicate that there is little relationship to pocket
depth for the majority of microbial species; however,
most species of the orange complex and all species of
the red complex increased significantly with
increasing pocket depth. A number of possible rea-
170
12
Counts x 105
Tf
Pg
Pmel
Pn
Pi
Lb Nm
Gm
Td Es
Pa
Fnv
An2
Cgr
Cg
Vp
An1
So Ss
Sm
Ag
Ai
Ao
Si
Sg
En
CrCs
Ec
Co
<3
Yellow
Purple
Pocket depth (mm) Actinos
Fp Pm
Sa
Sc
Fnp
Red
Csp
Aa
>8
Fnn
Sn Ts
Other
Orange
Green
Fig. 30. Mean counts ( 105) of 40 species in subgingival

plaque samples from different pocket depths in subjects
with periodontitis. Subgingival plaque samples were taken
from 14,577 sites in 588 subjects with chronic periodontitis at baseline and analyzed for their content of
40 subgingival species using checkerboard DNADNA
hybridization. Counts of each species were averaged in
each subject in the pocket depth categories of < 3, 3, 4, 5,
6, 7, 8, and > 8 mm and then averaged across subjects for

each category. The species were ordered in the microbial
complex species order presented in Fig. 28. The height of
each slice represents the mean counts for each species at
each pocket depth category. Only species of the red and
orange complexes were significantly related to pocket
depth after adjusting for multiple comparisons.
that site (Fig. 31). The members of the red and orange
complexes are significantly elevated at sites that
exhibit bleeding on probing, which was used as a
clinical indicator of periodontal inflammation. The
species that were elevated in inflamed sites may have
benefited from the inflammation in part because they
were closest to the source of the increased gingival
crevice fluid (first to the feeding trough) and in part
because this fluid might be enriched with tissue
degradation products that might favor the growth of
many of the species that require proteins or peptides
(e.g. P. gingivalis and T. denticola) or can use the
metabolic end products of other species for their
growth (e.g. Campylobacter species).
pocket depths 6 mm that bled on probing with the

microbiota in periodontally healthy sites in the same
individuals that had a pocket depth < 4 mm and did
not bleed on probing. Major significant differences
were found in the mean subgingival counts of many
species, particularly for the species of the red and
orange complexes, between the healthy and diseased
sites in subjects with advanced periodontitis. Superimposed on the profiles from the periodontitis subjects is the mean microbial profile derived from
samples from the periodontally healthy subgingival
sites of periodontally healthy subjects. There were
marked differences between periodontally healthy
sites in periodontally healthy subjects compared with
periodontally healthy sites in subjects with chronic
periodontitis for virtually all species examined. The
differences were most marked for orange and red
complex species. These data are in accord with the
findings of Riviere et al. (141) who demonstrated a
greater frequency of detection of spirochetes and
P. gingivalis in the healthy sites of periodontitis
subjects compared with the healthy sites of subjects
who were periodontally healthy (Fig. 2).
Comparison of the microbiota in

diseased and healthy sites of
periodontitis subjects with the healthy
sites in periodontally healthy subjects
Figure 32 compares the baseline mean subgingival
microbial profiles of periodontal sites that all periodontists would agree were diseased, i.e. sites with
171
Counts x 105
0.0
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. noxia
T. socranskii
1.3
2.6
4.0
5.3
Actinos
Purple
Yellow
Green
***
***
***
***
***
***
*
***
Orange
***
***
*
***
***
***
Red
Other
BOP negative
***
BOP positive

plaque samples from sites that did or did not bleed on
probing in subjects with periodontitis. Subgingival plaque
samples were taken from 6920 sites that bled on probing
and 7656 sites that did not bleed on probing in 588
subjects with chronic periodontitis at baseline and analyzed for their content of 40 subgingival species using
checkerboard DNADNA hybridization. Counts of each
species were averaged in each subject in sites that did or

did not bleed on probing and then averaged across subjects for each category. The species were ordered
according to the microbial complexes (156). Significance
of difference for each species between groups was
determined using the MannWhitney test and adjusted
for multiple comparisons (157): *P < 0.05; **P < 0.01;
***P < 0.001.
From a clinical perspective, these data suggest

that healthy sites in periodontitis subjects may be at
far greater risk for future periodontal breakdown
than healthy sites in periodontally healthy subjects.
From an ecologic point of view, the differences
between the two sets of healthy sites are difficult to
explain. The local factors considered to be important in the previous section, pocket depth and
bleeding on probing, were essentially the same in
the two groups. The question then becomes, why in
spite of local habitat similarities, were the microbiotas so different in the periodontitis and periodontally healthy subjects? The accurate answer is
that we dont know. One could speculate that the

larger numbers of organisms in the reservoirs of
deeper periodontal pockets may have continually
seeded adjacent sites so that low level colonization
at these sites eventually occurred. Another possibility is that the subject was already colonized at many
shallow periodontal sites before disease was initiated at some of the sites. Whatever, the reason for
the difference in levels in the periodontally healthy
sites, the presence of increased levels of periodontal
pathogens in periodontally healthy sites of subjects
with periodontitis is a serious treatment issue as will
be discussed elsewhere (65).
172

Counts x 105
0.0
3.2
A. gerencseriae
A. israelii
A. naeslundii 1
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
S. intermedius
S. mitis
S. oralis
S. sanguis
C. gingivalis
C. ochracea
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
E. saburreum
G. morbillorum
L. buccalis
N. mucosa
P. acnes
P. melaninogenica
S. anginosus
S. noxia
T. socranskii
6.5
Actinomyces
Purple
Yellow
Green
Healthy
PD < 4 mm, BOP
PD > 6 mm, BOP +
Orange
Red
Other
All species differed significantly among groups even after adjusting for
multiple comparisons

plaque samples from periodontally diseased and periodontally healthy sites in 209 subjects with advanced
periodontitis and periodontally healthy sites in 78 periodontally healthy subjects. Periodontally diseased sites in
periodontitis subjects had baseline pocket depths 6 mm
and bled on probing, while periodontally healthy sites
had pocket depths < 4 mm and did not bleed on probing
in both the periodontitis and periodontally healthy
Relationship of host level

parameters to subgingival biofilm
composition
The local factors that impact on the composition of
the oral microbiota, the nature of the surface to be
colonized and the clinical status of the habitat, were
described above. Of clinical importance, the supraand subgingival plaque associated with a periodontally healthy site were quite different from plaque
associated with inflamed and bleeding gingival tissues and deep periodontal pockets. There are also
factors unique to each host that markedly affect
subgingival plaque composition. Not all of the
potential host-influencing factors will be discussed
here, but the effect of certain key factors, including
genetic background, obesity and habits such as
cigarette smoking, on the subgingival plaque com-
groups. Subgingival plaque samples were taken at baseline and analyzed for their content of 40 subgingival
species using checkerboard DNADNA hybridization.
Counts of each species were averaged in each subject in a
given site category and then averaged across subjects for
each category. The species were ordered according to
microbial complex (156). All species differed significantly
among groups using the KruskalWallis test even after
adjusting for multiple comparisons (157).
position will be described below. In addition, it will

be suggested that the nature of the subgingival
microbiota can be influenced by the geographic
location of the individual.
As discussed in the Principles section, the host can
modify the level of colonizing species and possibly
modulate disease outcome by a mechanism known
as environmental feedback. An example of this is
illustrated in Fig. 33. Serum samples and samples of
subgingival plaque were taken from 48 subjects with
chronic periodontitis. Serum antibody levels to
P. gingivalis were determined by ELISA and levels of
P. gingivalis in subgingival plaque were determined
using cultural techniques. The data indicated a
significant inverse relationship between antibody
levels to P. gingivalis and levels of this species in
subgingival plaque, i.e. high levels of antibody to
P. gingivalis were associated with lowered levels of
P. gingivalis in the subgingival microbiota. Given
173
200
r(s) = 0.35
P < 0.05
ELISA UNITS
150
100
50
0
0
10
COUNTS x 105
Fig. 33. Plot of mean counts of P. gingivalis ( 105) and

serum antibody levels to P. gingivalis in 48 chronic periodontitis subjects. Each circle represents values for a
single subject. Regression analysis indicated a significant
negative relationship between counts of P. gingivalis in
subgingival plaque samples and serum antibody to that
species.
the significant association of this species with periodontal disease severity, decreasing its levels by
environmental feedback should help to limit disease
progression and augment therapeutic strategies.
Cigarette smoking
Numerous studies in the literature have examined the
relationship between cigarette smoking and the
clinical parameters of periodontal diseases. These
studies have indicated an increased level of periodontal disease in terms of more alveolar bone loss
(11, 56, 114, 123), deeper periodontal pockets (10, 11,
59, 126), and greater attachment level loss (3, 6, 7, 12,
15, 34, 42, 57, 58, 96, 97, 148) in subjects who currently smoke cigarettes compared with those individuals who are past smokers or who have never
smoked cigarettes. The same studies also indicated
that cigarette smokers have less bleeding on probing
compared with nonsmokers. While multiple studies
are consistent in showing strong relationships
between clinical periodontal data and cigarette
smoking, the effect of cigarette smoking on the
composition of the subgingival microbiota is less
clear. Some studies suggest that cigarette smoking
has little impact on subgingival plaque composition.
Preber et al. (127) in a study of 142 adult periodontitis
subjects showed that counts of A. actinomycetemcomitans, P. gingivalis, and P. intermedia were not
174
significantly different between smokers and

nonsmokers based on a single plaque sample per
subject taken from a site with pocket depth 6 mm.
Stoltenberg et al. (162) evaluated eight subgingival
plaque samples taken from a randomly selected
posterior sextant in each of 615 adults. Using
immunoassay, they found no significant differences
between smokers and nonsmokers in the prevalence
of test species A. actinomycetemcomitans, P. gingivalis, P. intermedia, E. corrodens, and F. nucleatum.
In a group of 25 young adults with gingivitis, Lie et al.
(85) found no difference between smokers and
nonsmokers in the counts of nine subgingival species
or groups in pooled supra- and subgingival plaque
samples, with the exception of higher counts of
Streptococcus species in the nonsmokers. Renvert
et al. (137) evaluated the effect of periodontal therapy
on the subgingival microbiota in smokers and
nonsmokers and suggested that the post-therapy
microbial change was consistent with clinical change
rather than the influence of cigarette smoking.
Other studies have found differences between the
subgingival microbiota of smokers and nonsmokers.
Eggert et al. (40) using immunoassay demonstrated
that P. gingivalis, P. intermedia, and A. actinomycetemcomitans were found more frequently in shallow
periodontal sites ( 5 mm) in smokers than in similar sites in nonsmokers. Kamma et al. (68) used
cultural techniques to examine two pooled plaque
samples from each of 60 early onset periodontitis
subjects. They found that proportions and or
prevalence of P. micros, Campylobacter concisus,
T. forsythia, C. rectus, Campylobacter gracilis,
Selenomonas sputigena, and P. gingivalis were significantly elevated in smokers, whereas Streptococcus
intermedius, A. naeslundii, Actinomyces israelii, and
Eubacterium lentum were significantly higher in
nonsmokers. Zambon et al. (187) found that smokers
had significantly higher levels of, and were at greater
risk of infection from, T. forsythia than were nonsmokers, and smokers were 2.3 times more likely to
harbor this periodontal pathogen than former or
nonsmokers after adjusting for disease severity.
Umeda et al. (173) found that past smokers had a
decreased risk of harboring A. actinomycetemcomitans in saliva (OR 0.23), while current smokers
had an increased risk of harboring T. denticola
subgingivally (OR 4.61), although the risk of colonization by T. forsythia, P. intermedia, P. gingivalis,
and P. nigrescens did not differ among smoking
groups. Data from our study that examined the
subgingival microbiota using checkerboard DNA
DNA hybridization, in 124 non smokers who had
never smoked, 98 past smokers, and 50 current

smokers indicated that there were no significant
differences in levels and proportions of the 29 test
species among the different smoking groups (64).
However, the prevalence (% of sites colonized) of
several orange, E. nodatum, F. nucleatum ss. vincentii, P. intermedia, P. micros, and P. nigrescens, as
well as all three red complex species P. gingivalis,
T. forsythia, and T. denticola was significantly
greater in smokers compared with past smokers or
those who had never smoked (Fig. 34). The difference in prevalence of subgingival species among
smoking groups was particularly marked at pockets
4 mm, whereas no significant differences were
observed at pockets >4 mm. The more widespread
colonization of periodontal pathogens in current
smokers compared with nonsmokers, particularly at
shallow sites, may account in part for the difficulty
in successfully treating periodontal infections in
these individuals.
Obesity
In the last decade, there has been an explosion of
concern in the popular press and medical literature
All sites
% sites colonized 0
25
50
about the increasing proportion of overweight and

obese individuals in first world populations. The
reason for this concern is that the risk for many
medically important conditions such as diabetes,
coronary heart disease, cancer and osteoarthritis is
increased in overweight or obese individuals (16, 19,
38, 71, 135, 136, 176). Indeed, it has been determined
that obesity will soon be the number one cause of
preventable disease and death, replacing smoking as
the major modifiable cause of disease (27).
Data from a number of cross-sectional studies have
suggested that there may be a relationship between
being overweight or obese and periodontitis. Data
from the NHANES III study indicated that there was a
relationship between an increased BMI and the
extent of periodontal attachment loss (181). A second
examination of the NHANES III data supported the
relationship of BMI and also abdominal obesity to
periodontal status and indicated that the relationship
occurred primarily in younger subjects (aged 18
34 years) with less of a relationship in middle-aged
and older adults (4). An increased BMI was also
associated with an increased risk of periodontitis in
Japanese subjects; particularly those with a high
waisthip ratio (144).
PD > 4 mm
75
10000
25
other
S. noxia
A. naeslundii 2 Actinomyces
A. odontolyticus
purple
V. parvula
S. gordonii
S. intermedius
yellow
S. mitis
S. oralis
S. sanguis
A. actinomycetemcom
C. gingivalis
C. ochracea
green
C. sputigena
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
*
F. nuc ss nucleatum
F. nuc ss polymorphum
orange
F. nuc ss vinventii
*
F. periodonticum
P. intermedia
*
P. micros
*
P. nigrescens
**
S. constellatus
T. forsythia
**
P. gingivalis
red
*
T. denticola
*
Fig. 34. Microbial profiles of the mean prevalence of 29

microbial taxa in subgingival plaque samples taken from
124 nonsmokers who had never smoked, 98 past smokers,
and 50 current smokers. The profiles represent the mean
prevalence (% of sites colonized) derived by averaging the
prevalence of each species across subjects in each smoking group. The left panel represents all sites, the center
50
PD <= 4 mm
75
100 00
25
50
75
100
other
other
purple
purple
yellow
yellow
Smoking
status
green
green
never
past
current
orange
orange
*
*
red
**
red
*
panel sites with pocket depth > 4 mm and the right panel
sites with pocket depth 4 mm. Significance of differences
among groups was sought using ANCOVA adjusting for
pocket depth and attachment level; *P < 0.05, **P < 0.01,
***P < 0.001. The species were ordered and grouped
according to the complexes described by Socransky et al.
(156). Data adapted from (64).
175
In ongoing studies at The Forsyth Institute, height

and weight were measured in 415 systemically healthy subjects with chronic periodontitis (n 329) or
periodontal health (n 86). Clinical periodontal
parameters were measured at six sites per tooth.
Subgingival plaque samples were collected from the
mesial aspect of each tooth and were individually
analyzed for their content of 40 bacterial species
using checkerboard DNADNA hybridization. Levels
and percentage DNA probe counts of each species
were determined for each site and averaged across
sites in each subject. BMI was computed for each
subject and subjects were divided into three subsets:
normal weight (BMI < 25, n 168), overweight (BMI
2530, n 136), and obese (BMI 30, n 111).
Then significance of differences in clinical and
microbial parameters among groups was tested using
ANCOVA, adjusting for age and smoking status. The
results indicated that the percent of normal, overweight, and obese subjects was 63%, 24%, and 13% in
periodontally healthy subjects and 30%, 35%, and
35% in periodontitis subjects, respectively (Fig. 35).
The percentage of obese subjects was significantly
higher in the periodontitis subjects (P < 0.001), and
the percentage of normal weight subjects was significantly higher in the healthy subjects (P < 0.001).
Subjects with elevated BMI exhibited a significantly
higher percentage of sites with plaque and bleeding
on probing as well as significantly greater mean
pocket depth and mean attachment level compared
with non-obese subjects (Fig. 36). Obesity was also
associated with increased counts and proportions of
certain periodontal pathogens, including T. forsythia.
100
13
Obese
P < 0.001
35
% of Subjects
75
24
Overweight
35
50
25
63
Normal
P < 0.001
30
0
Health
N = 86
Periodontitis
N = 329
Fig. 35. Stacked bar chart indicating the percentage of

periodontally healthy or periodontitis subjects who had a
BMI < 25 (normal), 2530 (overweight) or > 30 (obese).
The association between BMI category and periodontal
status was tested using Chi-squared analysis.
176
(Fig. 37). The increase in the proportion of T. forsythia

was particularly marked in extremely obese subjects
whose BMI was > 35. These data suggest that obese
subjects were more likely to exhibit periodontitis, had
greater mean pocket depth and percentage sites with
plaque, and higher proportions of T. forsythia than
overweight or normal weight subjects.
Effect of genetic background on

subgingival plaque composition
In 1997, Kornman et al. (79) provided data suggesting
that polymorphisms in the interleukin (IL)-1 gene
cluster appeared to relate to periodontal disease
status in nonsmokers. Subjects who exhibited allele 2
of polymorphisms in the genes for both the IL-1a and
IL-1b gene were far more likely to exhibit severe
periodontitis than subjects who did not exhibit these
polymorphisms. These genes are associated with
overexpression of cytokines associated with inflammation, IL-1a and IL-1b. The question was asked
whether subjects exhibiting different IL-1 polymorphisms would exhibit differences in subgingival biofilm composition. Socransky et al. (158) examined
the effect of IL-1 polymorphisms on clinical and
microbiological parameters of periodontitis. Six sites
per tooth were examined clinically and subgingival
plaque samples taken from each tooth were examined for their content of 40 bacterial species using
checkerboard DNADNA hybridization. In addition,
finger-stick blood samples were taken from each
subject and the extracted DNA used for genotyping of
IL-1 polymorphisms (79). They found that the major
difference in the subgingival microbiota between
genotype positive and negative subjects was at sites
with a pocket depth > 6 mm. Twelve of 29 species
were significantly elevated in pockets > 6 mm in
the genotype positive subjects compared with the
genotype negative subjects (Fig. 38). These species
included all three members of the red complex,
P. gingivalis, T. forsythia, T. denticola, seven members of the orange complex, C. gracilis, E. nodatum,
F. nucleatum ss. nucleatum, F. nucleatum ss. polymorphum, F. nucleatum ss. vincentii, F. periodonticum, and Streptococcus constellatus as well as
S. gordonii and S. intermedius. In contrast, there
were no significant differences in the subgingival
microbiota between genotype positive and negative
subjects at sites with pocket depths 6 mm. These
data suggest that the increased levels of primarily
orange and red complex species at deep sites of
genotype positive subjects may be due to increased
production of inflammatory cytokines producing an
Plaque
80
BOP
36
P < 0.001
P < 0.05
%
60
27
40
18
20
Pocket Depth
3.2
mm
Attachment Level
3.6
P < 0.01
OK
(n = 168)
mm
2.9
3.2
2.6
2.8
2.3
2.4
2.0
2.0
Overweight
(n = 136)
P < 0.001
Obese
(n = 111)
Fig. 36. Bar plots of mean periodontal clinical parameters

in subjects who had a BMI < 25 (normal), 2530 (overweight) or > 30 (obese). The bars represent values for each
clinical parameter averaged within each subject and then
averaged across subjects in each BMI group separately.

The whiskers represent the standard error of the mean.
Significance of differences among BMI groups for each
parameter was sought using the KruskalWallis test.
increased inflammatory response to the microbial

challenge. The increased inflammatory response
would lead to increased gingival crevice fluid, the
bulk fluid bathing the subgingival biofilm, which
provides nutrients to the bacteria in this biofilm.
The proximity of the orange and particularly the red
complex species to the epithelial lining of the periodontal pocket would insure that these species receive
the maximum benefit from the increased gingival
crevice fluid. Increased levels of these taxa would
affect the local tissues leading to increased inflammation and pocket deepening, which in turn would
foster growth of these species. In genotype positive
subjects, the interplay between the host and colonizing subgingival species was altered, favoring
increased gingival inflammation and subgingival
colonization by periodontal pathogens.
These differences were not surprising given the quite

different clinical manifestations in these two populations. It has been generally assumed, however, that
subjects with similar clinical conditions, for example
chronic periodontitis, would exhibit, on average,
similar subgingival microbial profiles irrespective of
the geographic location in which the subjects reside.
Several studies have indicated that the subgingival
species examined to date are commonly found in
many different populations throughout the world (17,
36, 119, 145, 186). However, studies that have directly
compared the microbiotas of subjects residing in
different geographic locations suggest that marked
differences in the range, levels, and prevalence of
subgingival species may exist (119, 145, 186).
A recent study (60) examined the composition of
the subgingival microbiota in subjects with chronic
periodontitis from four different geographic locations. Fifty-eight subjects from Brazil, 26 subjects
from Chile, 101 Swedish subjects, and 115 subjects
from Boston, USA, were clinically monitored and
subgingival plaque samples taken. The samples were
individually analyzed for their content of 39 bacterial
species using checkerboard DNADNA hybridization
Effect of geographic location on

subgingival plaque composition
In previous sections, significant differences in subgingival plaque composition between periodontally
healthy and periodontitis subjects were described.
177
Counts x 105
% DNA probe count
3.4
10.7
P < 0.01
P < 0.001
2.5
8.1
1.7
5.4
0.8
2.7
133
63
107
19
0.0
0.0
< 25
2529.9 3035
> 35
< 25
2529.9 3035
> 35
Body Mass Index

Fig. 37. Mean counts and proportions of T. forsythia in
subjects who had a BMI < 25 (normal), 2530 (overweight),
3035 (obese) or > 35 (extremely obese). Counts of
T. forsythia were determined using checkerboard DNA
DNA hybridization, averaged within each subject, and
then averaged across subjects in each BMI group sepa-
PD < 4 mm
Counts x 105 0
B. fragilis
B. ureolyticus
C. curvus
C. sputorum ss bub
C. sput ss sput
C. sputigena
P. endodontalis
S. noxia
W. succinogenes
A. naeslundii 2
A. odontolyticus
V. parvula
S. gordonii
Streptocuccu sp.
S. intermedius
S. mitis
S. oralis
S. sanguis
A. actino. a
A. actino. b
C. concisus
C. gingivalis
C. ochracea
C. sputigena 4
E. corrodens
C. gracilis
C. rectus
C. showae
E. nodatum
F. nuc. ss nucleatum
F. nuc. ss polym.
F. nuc. ss vincentii
F. periodonticum
P. micros
P. intermedia
P. nigrescens
S. constellatus
T. forsythia
P. gingivalis
T. denticola
22
PD 4 6 mm
44 0
22
PD > 6 mm
44
22
44
other
Actinomyces
purple
*
*
yellow
green
orange
** P < 0.05
**
** P < 0.01
***
*** P < 0.001
MannWhitney
test
**
*
*
**
red
PST negative N = 79
Fig. 38. Mean microbial profiles for chronic periodontitis

subjects who were PST negative (n 79) or positive (n 29).
The mean counts were derived by averaging the counts of
178
rately. The bars represent the mean values and the

whiskers the SEM. The numbers in the left hand set of bars
indicate the number of subjects examined in each group.
Significance of differences in T. forsythia counts and
proportions was determined using the KruskalWallis test
and P-values were adjusted for 40 comparisons (157).
**
**
PST postive N = 29
each species within a subject and then across subjects in the

two clinical groups. Significance of differences for each
species was determined using the MannWhitney test.
and the mean proportion of each species in each

subject computed. The data indicated marked differences among the four populations in the proportions of the test species (Fig. 39), with 12 of 39
test species differing significantly among groups.
The Brazilian subjects exhibited the highest mean
proportions of A. naeslundii genospecies 1, several
streptococci, including S. gordonii, S. sanguis,
S. intermedius, and S. constellatus, as well as
E. nodatum and T. denticola. The highest mean
proportions of P. gingivalis and F. periodonticum
were seen in the subjects from Chile, whereas the
Swedish subjects exhibited the highest mean proportions of Capnocytophaga gingivalis, C. gracilis,
P. micros, and Leptotrichia buccalis. Of particular
interest was the difference in the proportions of the
red complex species among the four subject groups
(Fig. 40). No significant difference was detected
among the four groups in the proportions of
T. forsythia, although this species was the dominant
red complex species in the Swedish subjects. Significant differences among groups were seen for both
P. gingivalis and T. denticola. The Chilean subjects
had the highest proportions of P. gingivalis compared with the other groups, and the Brazilians had
the highest proportions of T. denticola. It should be
noted that there were no significant differences
among groups in terms of clinical features, although
the racial ethnic background of the subjects differed
and the percentage of current smokers ranged from
2% in the Brazilians to 62% in the Swedish subjects.
Differences in the subgingival microbiotas of subjects with comparable levels of disease in different
geographic locations could impact on therapeutic
outcomes. It is likely that subjects with different
microbial profiles will respond differently to a given
periodontal therapy. In addition, these microbial
differences among subjects may partly explain the
differences in disease severity noted in different regions of the world.
% DNA probe count

10.20
7.65
5.10
2.55
0.00
USA
Sweden
Chile
Brazil
Fig. 39. Adjusted mean percents of the total DNA probe

count of 39 bacterial species in baseline subgingival plaque samples taken from 114 American, 101 Swedish, 26
Chilean, and 58 Brazilian subjects with chronic periodontitis. The top of each panel represents the mean percents after adjusting for age, mean pocket depth, gender,
and smoking status. Mean percents of each species were
computed by averaging samples from the four deepest
and three shallowest pocket depths sampled in each

subject, and then averaging across subjects in the four
countries. Significance of differences among groups was
sought using ANCOVA adjusting for age, mean pocket depth,
gender, and smoking status; *P < 0.05, **P < 0.01,
***P < 0.001 after adjusting for multiple comparisons
(157). The species were ordered and grouped according to
the complexes described in (156). Data derived from (60).
179
T. forsythia
% DNA
probe 0.0
count
6.5
P. gingivalis
13.0
0.0
NS
Brazil
13.0
0.0
P < 0.001
Chile
Fig. 40. Bar charts of adjusted mean percents ( SEM) of

the total DNA probe count of the red complex species,
T. forsythia, P. gingivalis, and T. denticola in baseline
subgingival plaque samples taken from the four deepest
and three shallowest, sampled periodontal pockets in 58
Brazilian, 26 Chilean, 101 Swedish, and 114 American
chronic periodontitis subjects. The bars represent the
Concluding remarks
By now the readers mind has probably turned to
Jello. The multiplicity of factors that appear to impact
on the nature of the oral microbiota may appear to be
overwhelming. For this reason, we have decided to
summarize some of the key elements that we feel are
essential to our understanding of the ecology of the
oral microbiota and the way that we may control oral
infections. The first is not exactly a news flash.
The mouth is not sterile. Whether we like it or not, the
oral cavity will be colonized by microorganisms.
The best that we can do is to guide the composition
of the microbiota to one that leads to sustained
freedom from the effects of oral infections. In order
to undertake this process, we must understand the
factors that govern microbial composition and
biological activity in order to nudge the microbiota
to one that is host compatible.
Habitat
One key recognition is that while the microbiota
affects its habitat, the habitat affects the composition
and metabolic processes of the colonizing species.
The habitat starts even outside the individual
(human) and may encompass factors controlled by
180
6.5
T. denticola
Sweden
6.5
13.0
P < 0.001
USA
mean percents after adjusting for age, mean pocket depth,

gender, and smoking status. The whiskers indicate the
standard error of the mean. Significance of differences
among groups for each species was sought using ANCOVA
adjusting for age, mean pocket depth, gender, and smoking status. The P-values were adjusted for 40 comparisons (157). Data derived from (60).
the geographic location of the individual, including

genetic background, raceethnicity, social customs,
socioeconomic status, dietary practices and, importantly, the nature of the organisms colonizing other
individuals in the same community. Once you move
from the human community to the human individual, there are unique host-level factors that play a
major role including his or her genetic makeup,
health status, diet, oral hygiene procedures, smoking
habits, drug use, and the individuals with whom
heshe interacts. When moving from the individual to
the oral cavity, there are additional factors that
influence microbial colonization. These include the
nature of the receptors on both the hard and soft
tissues for initial attachment of species, the nature of
the species already colonizing available surfaces, the
composition and nature of the major bulk fluid that
sustains these organisms and once more the efficacy
of self-performed oral hygiene measures. Data presented earlier indicate that each of these factors may
impact on the nature of colonizing organisms and
that species that colonize one area of the mouth have
the potential to move to and reside in other areas,
albeit in different numbers and proportions and
occupying different niches (roles).
The teeth provide an unique habitat for the colonization of organisms. A critical factor is that the
teeth (or dentures) are nonshedding surfaces and, as
such, allow development of very complex biofilms

with a dense glycocalyx. The composition of the
biofilms on the tooth is affected by the nature of the
surface provided, the other organisms in the biofilm,
and the nature of the bulk fluid. The receptors on the
tooth are most likely to be salivary proteins deposited
during the process of pellicle formation and these
proteins will differ from person to person based on
hisher unique genetic makeup. These proteins will
select organisms with specific adhesins and they may
attach, multiply, and provide the pioneer species
that set the stage for other colonizing bacteria.
The first species may provide points of attachment
(coaggregation) for other species or they may provide
the environment for growth of species by altering
physicochemical factors, providing nutrients or
degrading complex macromolecules to forms that
might be used by other species. Thus, the nature of
the species that enter into biofilm development very
much influences the nature of other species that
might inhabit the same site. We were impressed by
the speed at which this initial colonizing phase can
take place. Certain species may reach peak levels
within hours and many species will have attained
maximum growth in 14 days. However, this rapid
formation is analogous to the construction of a
house. The frame may go up quite rapidly (within
days), but the finished structure will take weeks to
months to complete. The abundance and composition of the bulk fluid bathing this area also will impact on the total numbers and proportions of species
on tooth surfaces. The data from the Sjogrens subjects suggest that decreased salivary flow limits the
growth of bacterial species on both tooth and soft
tissue surfaces and alters microbial composition.
Finally, supragingival plaque and soft tissue biofilms
harbor anaerobic species, including periodontal
pathogens, although the numbers may be small.
The teeth together with the gingival tissues provide
a unique domain for bacterial colonization, the subgingival environment. In this area, both hard and soft
tissue surfaces are available for colonization providing a situation in which two types of biofilms may
form. The first would initially be a subgingival
extension of the tooth-associated supragingival biofilm, and the second, the biofilm that develops on the
epithelial surface provided by the gingival sulcus or
periodontal pocket wall. Once more we have the
controlling themes of the nature of the surface(s) and
the nature of the bulk fluid that sustains colonization.
The soft tissue surface will differ from person to
person based on genetic background in terms of the
nature of the receptors provided for attachment of
oral bacteria. In addition, the colonizing species can

alter the epithelial surfaces, leading to different colonizing species (21). A third zone may also be
detected between the tooth and tissue-associated
biofilms. This zone is most evident in deeper periodontal pockets and consists of loosely adherent bacteria that can exist in deeper pockets because the
physical confinement of such pockets does not
demand the tenacious surface attachment needed for
the survival of most biofilms. The bulk fluid nourishing the subgingival biofilms is the gingival crevice
fluid. This fluid is markedly different in composition
from saliva and its composition and volume are
dramatically influenced by the inflammatory status
of the gingival tissues. Low gingival crevice fluid
volume may limit the growth of the subgingival biofilms, whereas increased gingival crevice fluid volume
containing breakdown products from the adjacent
tissues may enhance bacterial growth, fostering the
growth of specific species like P. gingivalis and
T. denticola that require breakdown products such as
proteins or peptides.
Climax community
A second key concept is the stability of the climax
community, i.e. the complex mixture of bacterial
species that occurs in mature biofilms. Eventually,
after the interplay of all the local habitat, host and
microbial determinants, a stable climax community
is established. The microorganisms in this community have achieved an equilibrium with each other
and with the habitat provided by the host. This
equilibrium is dynamic in that minor perturbations
are continuously occurring with adjustments made
by both the host and the colonizing species. Once
established, it is very difficult to make major changes
to this climax community. Short-term changes in the
host such as an upper respiratory infection, a brief
change in diet, a lapse in oral hygiene procedures
will modify the microbial community somewhat, but
the community will return to its climax state once
these factors are removed. Even periodontal therapy
may only have a temporary modifying effect on the
climax community, although therapies that provide
major alterations to the microbial community or the
habitat may lead to a new climax community that is
hopefully beneficial to the host. As we examine the
history of periodontal therapy, it is clear that a
number of empiric procedures were employed to
alter the subgingival microbiota with the hope that
these procedures would benefit the host. For the
most part, we had no idea as to the effects that these
181
procedures would have on the subgingival ecosystem. In recent years, a number of studies reviewed in
Haffajee & Socransky (65) have attempted to define
the shifts that occur as a result of individual or
combined therapies. The next stage in this development will be to provide the optimal periodontal
therapy to each subject in order to develop a climax
community that is stable and provides long-term
periodontal stability.
Whats next?
There is an awakened interest in the biomedical
community in the study of biofilms since biofilm
communities are responsible for the majority of
bacterial infectious diseases of the human. This is an
unique opportunity to meld in vitro, in vivo, and
translational research, but it is critical that these
three approaches be carried out in parallel with collaborative interactions. There is a great fear on the
part of the authors that the research community and
research administrators have become enraptured
with metagenomics, proteomics, and in vitro systems. Studies of this nature, in isolation, may have
little or unrecognized relevance to the in vivo ecosystem of interest. The challenge for the future will be
to balance in vitro, in vivo, and translational research
approaches so that major advances can be made in
our understanding of biofilm ecosystems.
Acknowledgments
This work was supported in part by research grants
DE-10977, DE-12108, DE-12861, DE-13232 from the
National Institute of Dental and Craniofacial
Research.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
References
1. Albandar JM, Brown LJ, Loe H. Putative periodontal
pathogens in subgingival plaque of young adults with and
without early-onset periodontitis. J Periodontol 1997: 68:
973981.
2. Alexander M. Microbial Ecology. New York: John Wiley &
Sons, 1971.
3. Alpagot T, Wolff LF, Smith QT, Tran SD. Risk indicators for
periodontal disease in a racially diverse urban population.
J Clin Periodontol 1996: 23: 982988.
4. Al-Zahrani MS, Bissada NF, Borawski EA. Obesity and
periodontal disease in young, middle-aged, and older
adults. J Periodontol 2003: 74: 610615.
5. Ashimoto A, Chen C, Bakker I, Slots J. Polymerase chain
reaction detection of 8 putative periodontal pathogens
182
20.
21.
22.
in subgingival plaque of gingivitis and advanced periodontitis lesions. Oral Microbiol Immunol 1996: 11: 266
273.
Axelsson P, Paulander J, Lindhe J. Relationship between
smoking and disease status in 35-, 50-, 65-, and 75-yearold individuals. J Clin Periodontol 1998: 25: 297305.
Beck JD, Cusmano L, Green-Helms W, Koch GG, Offenbacher S. A 5-year study of attachment loss in
community-dwelling older adults: incidence density.
J Periodontal Res 1997: 32: 506515.
Beck JD, Koch GG, Zambon JJ, Genco RJ, Tudor GE.
Evaluation of oral bacteria as risk indicators for periodontitis in older adults. J Periodontol 1992: 63: 9399.
Becker MR, Paster BJ, Leys EJ, Moeschberger ML, Kenyon
SG, Galvin JL, Boches SK, Dewhirst FE, Griffen AL.
Molecular analysis of bacterial species associated with
early childhood caries. J Clin Microbiol 2002: 40: 1001
1009.
Bergstrom J. Cigarette smoking as a risk factor in chronic
periodontal disease. Community Dent Oral Epidemiol
1989: 17: 245247.
Bergstrom J, Eliasson S. Cigarette smoking and alveolar
bone height in subjects with a high standard of oral
hygiene. J Clin Periodontol 1987: 14: 466469.
Bergstrom J, Preber H. Tobacco use as a risk factor.
J Periodontol 1994: 65: 545550.
Bloom RH, Brown LR. A study of the effects of orthodontic
appliances on the oral microbial flora. Oral Surg Oral Med
Oral Pathol 1964: 17: 658667.
Bowden GHW, Li YH. Nutritional influences on biofilm
development. Adv Dent Res 1997: 11: 8199.
Brown LF, Beck JD, Rozier RG. Incidence of attachment
loss in community-dwelling older adults. J Periodontol
1994: 65: 316323.
Calle EE, Thun MJ. Obesity and cancer. Oncogene 2004:
23: 63656378.
Cao CF, Aeppli DM, Liljemark WF, Bloomquist CG, Bandt
CL, Wolff LF. Comparison of plaque microflora between
Chinese and Caucasian population groups. J Clin Periodontol 1990: 17: 115118.
Carlsson J, Soderholm G, Almfeldt I. Prevalence of Streptococcus sanguis and Streptococcus mutans in the mouth
of persons wearing full dentures. Arch Oral Biol 1969: 14:
243249.
Carr MC, Brunzell JD. Abdominal obesity and dyslipidemia in the metabolic syndrome importance of type 2
diabetes and familial combined hyperlipidemia in coronary artery disease risk. J Clin Endocrinol Metab 2004:
89: 26012607.
Chaves ES, Jeffcoat MK, Ryerson CC, Snyder B. Persistent
bacterial colonization of Porphyromonas gingivalis,
Prevotella intermedia and Actinobacillus actinomycetemcomitans in periodontitis and its association with alveolar
bone loss after 6 months of therapy. J Clin Periodontol
2000: 27: 897903.
Childs WC III, Gibbons RJ. Selective modulation of bacterial attachment to oral epithelial cells by enzyme
activities associated with poor oral hygiene. J Periodontal
Res 1990: 25: 172178.
Choi BK, Park SH, Yoo YJ, Choi SH, Chai JK, Cho KS,
Kim CK. Detection of major putative periodontopathogens in Korean advanced periodontitis patients using a
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
nucleic acid-based approach. J Periodontol 2000: 71:

13871394.
Collins LMC, Dawes C. The surface area of the adult
human mouth and thickness of the salivary film covering
the teeth and oral mucosa. J Dent Res 1987: 66: 13001302.
Colombo AP, Haffajee AD, Dewhirst FE, Paster BJ, Smith
CM, Cugini MA, Socransky SS. Clinical and microbiological features of refractory periodontitis. J Clin Periodontol 1998: 25: 169180.
Daly CG, Highfield JE. Effect of localized experimental
gingivitis on early supragingival plaque accumulation.
Danser MM, van Winkelhoff AJ, van der Velden U. Periodontal bacteria colonizing oral mucous membranes in
edentulous patients wearing dental implants. J Periodontol 1997: 68: 209216.
Deen D. Metabolic syndrome: time for action. Am Fam
Physician 2004: 69: 28752882.
de Jong MH, van der Hoeven JS. The growth of oral bacteria on saliva. J Dent Res 1987: 66: 498505.
de Jong MH, van der Hoeven JS, van Os JH. Growth of
micro-organisms from supragingival dental plaque on
saliva agar. J Dent Res 1986: 65: 8588.
de Jong MH, van der Hoeven JS, van Os JH, Olijve JH.
Growth of oral Streptococcus species and Actinomyces
viscosus in human saliva. Appl Environ Microbiol 1984: 47:
901904.
Dibart S, Skobe Z, Snapp KR, Socransky SS, Smith C, Kent
R. Identification of bacterial species on or in crevicular
epithelial cells from healthy and periodontally diseased
patients using DNADNA hybridization. Oral Microbiol
Immunol 1998: 13: 3035.
Diem K. Documenta Geigy. Scientific Tables, 6th edn.
Ardsley NY: Geigy Pharmaceuticals, 1968: 517.
Di Murro C, Paolantonio M, Pedrazzoli V, Lopatin DE,
Cattabriga M. Occurrence of Porphyromonas gingivalis,
Bacteroides forsythus and Treponema denticola in periodontally healthy and diseased subjects as determined by
an ELISA technique. J Periodontol 1997: 68: 1823.
Dolan TA, Gilbert GH, Ringelberg ML, Legler DW,
Antonson DE, Foerster U, Heft MW. Behavioral risk indicators of attachment loss in adult Floridians. J Clin
Periodontol 1997: 24: 223232.
Douglas CWI, Pease AA, Whiley RA. Amylase-binding as a
discriminator among oral streptococci. FEMS Microbiol
Lett 1990: 66: 193198.
Dowsett SA, Kowolik MJ, Archila LA, Eckert GJ, LeBlanc
DJ. Subgingival microbiota of indigenous Indians of
Central America. J Clin Periodontol 2002: 29: 159167.
Dzink JL, Socransky SS, Haffajee AD. The predominant
cultivable microbiota of active and inactive lesions of
destructive periodontal diseases. J Clin Periodontol 1998:
15: 316323.
Eaton CB. Obesity as a risk factor for osteoarthritis:
mechanical versus metabolic. Med Health R I 2004: 87:
201204.
Eger T, Zoller L, Muller HP, Hoffman S, Lobinsky D.
Potential diagnostic value of sampling oral mucosal surfaces for Actinobacillus actinomycetemcomitans in young
adults. Eur J Oral Sci 1996: 104: 112117.
Eggert FM, McLeod MH, Flowerdew G. Effects of smoking
and treatment status on periodontal bacteria: evidence
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
that smoking influences control of periodontal bacteria at

the mucosal surface of the gingival crevice. J Periodontol
2001: 72: 12101220.
Ellen RP, Galimanas VB. Spirochetes at the forefront of
periodontal infections. Periodontol 2000 2005: 38: 1332.
Elter JR, Beck JD, Slade GD, Offenbacher S. Etiologic
models for incident periodontal attachment loss in older
adults. J Clin Periodontol 1999: 26: 113123.
Emilson C-G, Thorselius I. Prevalence of mutans streptococci and lactobacilli in elderly Swedish individuals.
Scand J Dent Res 1988: 96: 1421.
Frisken KW, Tagg JR, Orr MB. Suspected periodontopathic
microorganisms and their oral habitats in young children.
Oral Microbiol Immunol 1987: 2: 6064.
Ganong WG. Review of Medical Physiology, 12th edn. Los
Altos: Lang, 1985: 399.
Gersdorf H, Meissner A, Pelz K, Krekeler G, Goel UB.
Identification of Bacteroides forsythus in subgingival plaque from patients with advanced periodontitis. J Clin
Microbiol 1993: 3: 941946.
Gersdorf H, Pelz K, Gobel UB. Fluorescence in situ
hybridization for direct visualization of gram-negative
anaerobes in subgingival plaque samples. FEMS Immunol
Med Microbiol 1993: 6: 109114.
Gibbons RJ, Hay DI, Cisar JO, Clark WB. Adsorbed salivary
proline-rich protein-1 and statherin: Receptors for type 1
fimbriae of Actinomyces viscosus T14V-J1 on apatitic surfaces. Infect Immun 1988: 56: 29902993.
Gibbons RJ, Hay DI, Schlesinger DH. Delineation of a
segment of adsorbed salivary acidic proline-rich
proteins which promotes adhesion of Streptococcus
gordonii to specific surfaces. Infect Immun 1991: 59:
29482954.
Gibbons RJ, Nygaard M. Interbacterial aggregation of
plaque bacteria. Arch Oral Biol 1970: 15: 13971400.
Gmur R, Marinello CP, Guggenheim B. Periodontitis
associated bacteria in supragingival plaque of dental
hygienists: stability of carrier state and clinical development. Eur J Oral Sci 1999: 107: 225228.
Gmur R, Strub JK, Guggenheim B. Prevalence of Bacteroides forsythus and Bacteroides gingivalis in subgingival
plaque of prosthodontically treated patients on short
recall. J Periodontal Res 1989: 24: 113120.
Gmur R, Thurnheer T. Direct quantitative differentiation
between Prevotella intermedia and Prevotella nigrescens
in clinical specimens. Microbiology 2002: 148: 13791387.
Goh CJW, Waite IM, Groves BJ, Cornick DER. The influence of gingival inflammation and pocketing on the rate
of plaque formation during non-surgical periodontal
treatment. Br Dent J 1986: 161: 165169.
Griffen AL, Becker MR, Lyons SR, Moeschberger ML,
Leys EJ. Prevalence of Porphyromonas gingivalis and
periodontal health status. J Clin Microbiol 1998: 36:
32393242.
Grossi SG, Genco RJ, Machtei EE, Ho A, Koch G, Dunford
RG, Zambon JJ, Hausmann E. Assessment of risk for
periodontal disease. II. Indicators for alveolar bone loss.
J Periodontol 1994: 65: 2329.
Grossi SG, Zambon JJ, Ho AW, Koch G, Dunford RG,
Machtei EE, Norderyd OM, Genco RJ. Assessment of risk
for periodontal disease. I. Indicators for attachment loss.
J Periodontol 1994: 65: 260267.
183

58. Gunsolley JC, Quinn SM, Tew J, Gooss CM, Brooks CN,
Schenkein HA. The effect of smoking on individuals with
minimal periodontal destruction. J Periodontol 1998: 69:
165170.
59. Haber J, Wattles J, Crowley M, Mandell R, Joshipura K,
Kent RL. Evidence for cigarette smoking as a major risk
factor for periodontitis. J Periodontol 1993: 64: 1623.
60. Haffajee AD, Bogren A, Hasturk H, Feres M, Lopez N,
Socransky SS. Subgingival microbiota of chronic periodontitis subjects from different geographic locations.
61. Haffajee AD, Cugini MA, Tanner A, Pollack RP, Smith C,
Kent RL Jr, Socransky SS. Subgingival microbiota in
healthy, well-maintained elder and periodontitis subjects.
62. Haffajee AD, Dzink JL, Socransky SS. Effect of modified
widman flap surgery and systemic tetracycline on the
subgingival microbiota of periodontal lesions. J Clin
Periodontol 1988: 15: 255262.
63. Haffajee AD, Socransky SS. Microbial etiological agents of
destructive periodontal diseases. Periodontol 2000 1994:
5: 78111.
64. Haffajee AD, Socransky SS. Relationship of cigarette
smoking to the subgingival microbiota. J Clin Periodontol
2001: 28: 377388.
65. Haffajee AD, Socransky SS. Modification of the subgingival biofilm by periodontal therapy. Periodontol 2000. (in
preparation).
66. Handleman SL, Mills JR. Enumeration of selected bacterial groups. J Dent Res 1965: 44: 13431353.
67. Hillam DG, Hull TS. The influence of experimental gingivitis on plaque formation. J Clin Periodontol 1977: 4: 5661.
68. Kamma JJ, Nakou M, Baehni PC. Clinical and microbiological characteristics of smokers with early onset periodontitis. J Periodontal Res 1999: 34: 2533.
69. Kawada M, Yoshida A, Suzuki N, Nakano Y, Saito T, Oho T,
Koga T. Prevalence of Porphyromonas gingivalis in relation to periodontal status assessed by real-time PCR. Oral
Microbiol Immunol 2004: 19: 289292.
70. Keyes PH. Microbiologically monitored and modulated
periodontal therapy. Gen Dent 1985: 33: 105115.
71. Khaodhiar L, McCowen KC, Blackburn GL. Obesity and its
comorbid conditions. Clin Cornerstone 1999: 2: 1731.
72. Kigure T, Saito A, Seida K, Yamada S, Ishihara K, Okuda K.
Distribution of Porphyromonas gingivalis and Treponema
denticola in human subgingival plaque at different periodontal pocket depths examined by immunohistochemical methods. J Periodontal Res 1995: 30: 332341.
73. Klein MI, Goncalves RB. Detection of Tannerella forsythensis (Bacteroides forsythus) and Porphyromonas gingivalis by polymerase chain reaction in subjects with
different periodontal status. J Periodontol 2003: 74: 798
802.
74. Kolenbrander PE, Ganeshkumar N, Cassels FJ, Hughes CV.
Coaggregation: specific adherence among human oral
plaque bacteria. FASEB J 1993: 7: 406413.
75. Kolenbrander PE, London J. Adhere today, here tomorrow: oral bacterial adherence. J Bacteriol 1993: 175:
32473252.
76. Kononen E, Asikainen S, Alaluusua S, Kononen M, Summanen P, Kanervo A, Jousimies-Somer H. Are certain oral
pathogens part of normal oral flora in denture-wearing
184
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
edentulous subjects? Oral Microbiol Immunol 1991: 6:

119122.
Kononen E, Asikainen S, Jousimies-Somer H. The early
colonization of gram-negative anaerobic bacteria in
edentulous infants. Oral Microbiol Immunol 1992: 7: 2831.
Kononen E, Jousimies-Somer H, Asikainen S. Relationship
between oral gram-negative anaerobic becteria in saliva
of the mother and the colonization of her edentulous infant. Oral Microbiol Immunol 1992: 7: 273276.
Kornman KS, Crane A, Wang H-Y, di Giovine FS, Newman
MG, Pirk FW, Wilson TG Jr, Higginbottom FL, Duff GW.
The interleukin-1 genotype as a severity factor in adult
periodontal disease. J Clin Periodontol 1997: 24: 7277.
Kumar PS, Griffen AL, Barton JA, Paster BJ, Moeschberger
ML, Leys EJ. New bacterial species associated with chronic periodontitis. J Dent Res 2003: 82: 338344.
Lagerlof F, Dawes C. The volume of saliva in the mouth
before and after swallowing. J Dent Res 1984: 63: 618621.
Leys EJ, Griffen AL, Strong SJ, Fuerst FP. Detection and
strain identification of Actinobacillus actinomycetemcomitans by nested PCR. J Clin Microbiol 1994: 32: 12881294.
Leys EJ, Lyons SR, Moeschberger ML, Rumpf RW, Griffen
AL. Association of Bacteoides forsythus and a novel Bacteroides phylotype with periodontitis. J Clin Microbiol
2002: 40: 821825.
Li J, Helmerhorst EJ, Leone CW, Troxler RF, Yaskell T,
Haffajee AD, Socransky SS, Oppenheim FG. Identification
of early microbial colonizers in human dental biofilm.
J Appl Microbiol 2004: 97: 13111318.
Lie MA, van der Weijden GA, Timmerman MF, Loos BG,
van Steebergen TJM, van der Velden U. Oral microbiota
in smokers and non-smokers in natural and experimentally induced gingivitis. J Clin Periodontol 1998: 25:
677686.
Listgarten MA. Structure of the microbial flora associated
with periodontal health and disease in man. A light and
electron microscopic study. J Periodontol 1976: 47: 118.
Listgarten MA. Formation of dental plaque and other oral
biofilms. In: Newman HN, Wilson M, editors. Dental
Plaque Revisited. Cardiff: Bioline, 1999: 187210.
Listgarten MA, Hellden L. Relative distribution of bacteria
at clinically healthy and periodontally diseased sites in
humans. J Clin Periodontol 1978: 5: 115132.
Listgarten MA, Mayo HE, Tremblay R. Development of
dental plaque on epoxy resin crowns in man. A light and
electron microscopic study. J Periodontol 1975: 46: 1026.
Loe H, Theilade E, Jensen SB. Experimental gingivitis in
man. J Periodontol 1965: 36: 177187.
Loesche WJ. The role of Streptococcus mutans in human
dental decay. Microbiol Rev 1986: 50: 353380.
Lotufo RF, Flynn J, Chen C, Slots J. Molecular detection of
Bacteroides forsythus in human periodontitis. Oral
Ludwig JA, Reynolds JF. Statistical Ecology. New York:
John Wiley and Son, 1988.
Lundgren T, Renvert S, Papapanou PN, Dahlen G. Subgingival microbial profile of Papillion-Lefevre patients
assessed by DNA-probes. J Clin Periodontol 1998: 25: 624
629.
Lyons SR, Griffen AL, Leys EJ. Quantitative real-time PCR
for Porphyromonas gingivalis and total bacteria. J Clin
Microbiol 2000: 38: 23622365.

96. Machtei EE, Dunford R, Hausmann E, Grossi SG, Powell J,
Cummins D, Zambon JJ, Genco RJ. Longitudinal study of
prognostic factors of established periodontitis patients.
97. Machtei EE, Hausman E, Dunford R, Grossi S, Ho A, Davis
G, Chandler J, Zambon J, Genco RJ. Longitudinal study of
predictive factors for periodontal disease and tooth loss.
98. Mager DL, Ximenez-Fyvie LA, Haffajee AD, Socransky SS.
Distribution of selected bacterial species on intraoral
surfaces. J Clin Periodontol 2003: 30: 644654.
99. Mayanagi G, Sato T, Shimauchi H, Takahashi N. Detection
frequency of periodontitis-associated bacteria by polymerase chain reaction in subgingival and supragingival
plaque of periodontitis and healthy subjects. Oral Microbiol Immunol 2004: 19: 379385.
100. McBride BC, Gislow MT. Role of sialic acid in saliva
induced aggregation of Streptococcus sanguis. Infect
Immun 1977: 18: 3540.
101. McClellan DL, Griffen AL, Leys EJ. Age and prevalence of
Porphyromonas gingivalis in children. J Clin Microbiol
1996: 34: 20172019.
102. Meurman JH, Wahlfors J, Korhonen A, Alakuijala P, Vaisanen P, Torkko H, Janne J. Identification of Bacteroides
forsythus in subgingival dental plaque with the aid of a
rapid PCR method. J Dent Res 1997: 76: 13761380.
103. Moncla BJ, Braham P, Dix K, Watanabe S, Schwartz D. Use
of synthetic oligonucleotide DNA probes for the identification of Bacteroides gingivalis. J Clin Microbiol 1990: 28:
324327.
104. Moncla BJ, Braham PH, Persson GR, Page RC, Weinberg A.
Direct detection of Porphyromonas gingivalis in Macaca
fascicularis dental plaque samples using an oligonucleotide probe. J Periodontol 1994: 65: 398403.
105. Moore WEC, Moore LH. The bacteria of periodontal diseases. Periodontol 2000 1994: 5: 6677.
106. Moter A, Hoenig C, Choi BK, Riep B, Gobel UB. Molecular
epidemiology of oral treponemes associated with periodontal disease. J Clin Microbiol 1998: 36: 13991403.
107. Muller HP, Eickholz P, Heinecke A, Pohl S, Muller RF,
Lange DE. Simultaneous isolation of Actinobacillus
actinomycetemcomitans from subgingival and extracrevicular locations of the mouth. J Clin Periodontol 1995: 22:
413419.
108. Muller HP, Lange DE, Muller RF. Actinobacillus actinomycetemcomitans recovery from extracrevicular locations of the mouth. Oral Microbiol Immunol 1993: 8:
344348.
109. Muller HP, Zoller L, Eger T, Hoffman S, Lobinsky D.
Natural distribution of Actinobacillus actinomycetemcomitans in young men with minimal periodontal disease.
J Periodontal Res 1996: 31: 373380.
110. Noiri Y, Ebisu S. Identification of periodontal diseaseassociated bacteria in the plaque-free zone. J Periodontol
2000: 71: 13191326.
111. Noiri Y, Li L, Ebisu S. The localization of periodontaldisease associated bacteria in human periodontal pockets.
J Dent Res 2001: 80: 19301934.
112. Noiri Y, Li L, Yoshimura F, Ebisu S. Localization of
Porphyromonas gingivalis-carrying fimbriae in situ in
human periodontal pockets. J Dent Res 2004: 83: 941
945.
113. Noiri Y, Ozaki K, Nakae H, Matsuo T, Ebisu S. An immunohistochemical study on the localization of Porphyromonas gingivalis, Campylobacter rectus and Actinomyces
viscosus in human periodontal pockets. J Periodontal Res
1997: 32: 598607.
114. Norderyd O, Hugoson A. Risk of severe periodontal disease in a Swedish adult population. A cross-sectional
study. J Clin Periodontol 1998: 28: 10221028.
115. Nowicki D, Bogel RI, Melcher S, Deasey MJ. The gingival
bleeding time index. J Periodontol 1981: 52: 260262.
116. Papapanou PN, Baelum V, Luan WM, Madianos PN, Chen
X, Fejerskov O, Dahlen G. Subgingival microbiota in adult
Chinese: prevalence and relation to periodontal disease
progresssion. J Periodontol 1997: 68: 651666.
117. Papapanou PN, Madianos PN, Dahlen G, Sandros J.
Checkerboard versus culture: a comparison between two
methods for identification of subgingival microbiota. Eur J
Oral Sci 1997: 105: 389396.
118. Papapanou PN, Neiderud AM, Papadimitriou A, Sandros J,
Dahlen G. Checkerboard assessments of periodontal
microbiota and serum antibody responses: a case-control
study. J Periodontol 2000: 71: 885897.
119. Papapanou PN, Teanpaisan R, Obiechina NS, Pithpornchaiyakul W, Pongpaisal S, Pisuithanakan S, Baelum
V, Fejerskov O, Dahlen G. Periodontal microbiota and
clinical periodontal status in a rural sample in southern
Thailand. Eur J Oral Sci 2002: 110: 345352.
120. Paster BJ. The breadth of bacterial diversity in the human
periodontal pocket. Periodontol 2000 (in preparation).
121. Paster BJ, Boches SK, Galvin JL, Ericson RE, Lau CN,
Levanos VA, Sahasrabudhe A, Dewhirst FE. Bacterial
diversity in human subgingival plaque. J Bacteriol 2001:
183: 37703783.
122. Paster BJ, Bartoszyk IM, Dewhirst FE. Identification of oral
streptococci using PCR-based, reverse-capture, checkerboard hybridization. Methods Cell Sci 1998: 20: 223231.
123. Persson RE, Hollender LG, Persson GR. Assessment of
alveolar bone levels from intraoral radiographs in subjects
between 15 and 94 years seeking dental care. J Clin Periodontol 1998: 25: 647654.
124. Petit MD, van Steenbergen TJ, de Graaf J, van der Velden
U. Transmission of Actinobacillus actinomycetemcomitans
in families of adult periodontitis subjects. J Periodontal
Res 1993: 28: 335345.
125. Petit MD, van Steenbergen TJ, Scholte LM, van der Velden
U, de Graaf J. Epidemiology and transmission of
Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans among family members. A report of 4
surveys. J Clin Periodontol 1993: 20: 641650.
126. Preber H, Bergstrom J. Cigarette smoking in patients
referred for periodontal treatment. Scand J Dent Res 1986:
94: 102108.
127. Preber H, Bergstrom J, Linder LE. Occurrence of periopathogens in smoker and non-smoker patients. J Clin
Periodontol 1992: 19: 667671.
128. Preus HR, Zambon JJ, Dunford RG, Genco RJ. The distribution and transmission of Actinobacillus actinomycetemcomitans in families with established adult
periodontitis. J Periodontol 1994: 65: 27.
129. Quirynen M, Dekeyeser C, Steenberghe D. The influence
of gingival inflammation, tooth type and timing on the
rate of plaque formation. J Periodontol 1991: 62: 219222.
185

130. Radford JR, Beighton D, House F. Development of dental
plaque on the incisor teeth of monkeys (Macaca fascicularis). J Dent 1992: 20: 145151.
131. Ramberg P, Axelsson P, Lindhe J. Plaque formation at
healthy and inflamed gingival sites in young individuals.
132. Ramberg P, Furuichi Y, Volpe AR, Gaffar A, Lindhe J. The
effects of antimicrobial mouthrinses on de novo plaque
formation at sites with healthy and inflamed gingivae.
133. Ramberg P, Lindhe J, Dahlen G, Volpe AR. The influence
of gingival inflammation on de novo plaque formation.
134. Ramberg P, Sekino S, Uzel NG, Socransky S, Lindhe J.
Bacterial colonization during de novo plaque formation.
135. Rao SV, Donahue M, Pi-Sunyer FX, Fuster V. Results of
expert meetings: obesity and cardiovascular disease.
Obesity as a risk factor in coronary artery disease. Am
Heart J 2001: 142: 11021107.
136. Reaven G, Abbasi F, McLaughlin T. Obesity, insulin
resistance and cardiovascular disease. Recent Prog Horm
Res 2004: 59: 207223.
137. Renvert S, Dahlen G, Wikstrom M. The clinical and
microbiological effects of non-surgical periodontal therapy in smokers and non-smokers. J Clin Periodontol 1998:
25: 153157.
138. Richardson CT, Feldman M. Salivary response to food in
humans and its effect on gastric acid secretion. Am J
Physiol 1986: 250: G85G91.
139. Richardson RL, Jones M. A bacteriologic census of human
saliva. J Dent Res 1958: 37: 697709.
140. Ritz HL. Microbial population shifts in developing human
dental plaque. Arch Oral Biol 1967: 12: 15611568.
141. Riviere GR, Smith KS, Tzagaroulaki E, Kay SL, Zhu X,
DeRouen TA, Adams DF. Periodontal status and detection
frequency of bacteria at sites of periodontal health and
gingivitis. J Periodontol 1996: 67: 109115.
142. Roberts SK, Bass C, Brading M, Lappin-Scott H, Stoodley
P. Biofilm information and structure: Whats new? In:
Newman HN, Wilson M, eds. Dental Plaque Revisited.
Cardiff: Bioline, 1999: 1535.
143. Saarela M, von Troil-Linden B, Torrko H, Stucki AM,
Alaluusua S, Jousimies-Somer H, Asikainen S. Transmission of oral bacterial species between spouses. Oral
144. Saito T, Shimazaki Y, Koga T, Tsuzuki M, Ohshima A.
Relationship between upper body obesity and periodontitis. J Dent Res 2001: 80: 16311636.
145. Sanz M, van Winkelhoff AJ, Herrera D, Dellemijn-Kippuw
N, Simon R, Winkel E. Differences in composition of the
subgingival microbiota of two periodontitis populations of
different geographical origin. A comparison between Spain
and The Netherlands. Eur J Oral Sci 2000: 108: 383392.
146. Saxton CA. Scanning electron microscope study of the
formation of dental plaque. Caries Res 1973: 7: 102109.
147. Scannapieco FA, Bergey EJ, Reddy MS, Levine MJ. Characterization of salivary a-amylase binding to Streptococcus
sanguis. Infect Immun 1989: 57: 28532863.
148. Schenkein HA, Gunsolley JC, Koertge TE, Schenkein JG,
Tew J. Smoking and its effects on early-onset periodontitis. J Am Dent Assoc 1995: 126: 11071113.
186
149. Sharawy AM, Sabharwal K, Socransky SS, Lobene RR. A

quantitative study of plaque and calculus formation in
normal and periodontally involved mouths. J Periodontol
1966: 37: 495501.
150. Shibata S, Nagata K, Nakamura R, Tsunemitsu A, Misaki
A. Interaction of parotid saliva basic glycoprotein with
Streptococcus sanguis ATCC 10557. J Periodontol 1980: 51:
499504.
151. Simonson LG, Goodman CH, Morton HE. Quantitative
immunoassay of Treponema denticola serovar C in adult
periodontitis. J Clin Microbiol 1990: 28: 14931496.
152. Singleton S, Cahill JG, Watson GK, Allison C, Cummins D,
Thurnheer T, Guggenheim B, Gmur R. A fully automated
microscope bacterial enumeration system for studies of
oral microbial ecology. J Immunoassay Immunochem
2001: 22: 253274.
153. Socransky SS, Gibbons RJ, Dale AC, Bortnick L, Rosenthal E,
Macdonald JB. The microbiota of the gingival crevice
area of man. I. Total microscopic and viable counts and
counts of specific organisms. Arch Oral Biol 1963: 8: 275
280.
154. Socransky SS, Haffajee AD. Evidence of bacterial etiology:
a historical perspective. Periodontol 2000 1994: 5:
725.
155. Socransky SS, Haffajee AD. Dental biofilms: difficult
therapeutic targets. Periodontology 2000 2002: 28: 1255.
156. Socransky SS, Haffajee AD, Cugini MA, Smith C, Kent RL
Jr. Microbial complexes in subgingival plaque. J Clin
Periodontol 1998: 25: 134144.
157. Socransky SS, Haffajee AD, Smith C, Dibart S. Relation of
counts of microbial species to clinical status at the site.
158. Socransky SS, Haffajee AD, Smith C, Duff GW. Microbiological parameters associated with IL-1 gene polymorphisms in periodontitis patients. J Clin Periodontol 2000:
27: 810818.
159. Socransky SS, Haffajee AD, Smith C, Martin L, Haffajee JA,
Uzel NG, Goodson JM. The use of checkerboard DNA
DNA hybridization to study complex microbial ecosystems. Oral Microbiol Immunol 2004: 19: 352362.
160. Socransky SS, Haffajee AD, Ximenez-Fyvie LA, Feres M,
Mager D. Ecological considerations in the treatment of
Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis periodontal infections. Periodontol 2000
1999: 20: 341362.
161. Socransky SS, Manganiello AD, Propas D, Oram V, van
Houte J. Bacteriological studies of developing supragingival dental plaque. J Periodontal Res 1977: 12: 90
106.
162. Stoltenberg JL, Osborn JB, Pihlstrom BL, Hertzberg MC,
Aeppli DM, Wolff LF, Fischer GE. Association between
cigarette smoking, bacterial pathogens, and periodontal
status. J Periodontol 1993: 64: 12251230.
163. Solis-Gaffar MC, Rustogi KN, Gaffar A. Hydrogen sulphide
production from gingival crevicular fluid. J Periodontol
1980: 51: 603606.
164. Stoodley P, Boyle JD, Lappin-Scott HM. Biofilm structure
and behaviour; influence of hydrodynamics and nutrients. In: Newman HN, Wilson M, editors. Dental Plaque
Revisited. Cardiff: Bioline, 1999: 6372.
165. Stromberg N, Boren T. Actinomyces tissue specificity may
depend on differences in receptor specificity for GalNAcb-
166.
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
177.
containing glycoconjugates. Infect Immun 1992: 60: 3268

3277.
Stromberg N, Boren T, Carlen A, Olsson J. Salivary
receptors for GalNAcb-sensitive adherence of Actinomyces
spp: evidence for heterogeneous GalNAcb and prolinerich receptor properties. Infect Immun 1992: 60: 3278
3286.
Takeuchi Y, Umeda M, Sakamoto M, Benno Y, Huang Y,
Ishikawa I. Treponema denticola and Porphyromonas
gingivalis are associated with severity of periodontal tissue destruction. J Periodontol 2001: 72: 13541363.
Theilade E, Budtz-Jorgensen E. Predominant cultivable
microflora of plaque on removable dentures in patients
with denture-induced stomatitis. Oral Microbiol Immunol
1988: 3: 813.
Theilade E, Budtz-Jorgensen E, Theilade J. Predominant
cultivable microflora of plaque on removable dentures in
patients with healthy oral mucosa. Arch Oral Biol 1983:
28: 675680.
Theilade E, Wright WH, Jensen SB, Loe H. Experimental
gingivitis in man. II. A longitudinal clinical and bacteriological investigation. J Periodontal Res 1966: 1: 113.
Tsuchida K, Hara K. Clinical significance of gingival fluid
measurement by Periotron. J Periodontol 1981: 52: 697
700.
Tuite-McDonnell M, Griffen AL, Moeschberger ML, Dalton RE, Fuerst PA, Leys EJ. Concordance of Porphyromonas gingivalis colonization in families. J Clin Microbiol
1997: 35: 455461.
Umeda M, Chen C, Bakker I, Contreras A, Morrison JL,
Slots J. Risk indicators for harboring periodontal pathogens. J Periodontol 1998: 69: 11111118.
van der Hoeven JS, de Jong MH, van Nieuw Amerongen A.
Growth of oral microflora on saliva from different glands.
Microbial Ecol Health Dis 1989: 2: 171180.
van Steenbergen TJ, Petit MD, Scholte LH, van der Velden
U, de Graaf J. Transmission of Porphyromonas gingivalis
between spouses. J Clin Periodontol 1993: 20: 340345.
Vega GL. Obesity and metabolic syndrome. Minerva
Endocrinol 2004: 29: 4754.
Wang SL, Zhao ZT, Li J, Zhu XZ, Dong H, Zhang YG.
Investigation of the clinical value of total saliva flow rates.
Arch Oral Biol 1998: 43: 3943.
178. Watanabe S, Dawes C. The effects of different foods and

concentrations of citric acid on the flow rate of whole
saliva in man. Arch Oral Biol 1988: 33: 15.
179. Watanabe S, Ohnishi M, Imai K, Kawano E, Igarashi S.
Estimation of the total saliva volume produced per day in
five-year-old children. Arch Oral Biol 1995: 40: 781782.
180. Wimpenny J. Laboratory models of biofilm. In: Newman
HN, Wilson M, editors. Dental Plaque Revisited. Cardiff:
Bioline, 1999: 6372.
181. Wood N, Johnson RB, Streckfus CF. Comparison of body
composition and periodontal disease using nutritional
assessment techniques. Third National Health and
Nutrition Examination Survey (NHANES III). J Clin Periodontol 2003: 30: 321327.
182. Wyss C. Dependence of proliferation of Bacteroides
forsythus on exogenous N-acetylmuramic acid. Infect
Immun 1989: 57: 17571759.
183. Ximenez-Fyvie LA, Haffajee AD, Socransky SS. Comparison of the microbiota of supra- and subgingival plaque in
subjects in health and periodontitis. J Clin Periodontol
2000: 27: 648657.
184. Ximenez-Fyvie LA, Haffajee AD, Socransky SS. Microbial
composition of supra- and subgingival plaque in subjects
with adult periodontitis. J Clin Periodontol 2000: 27: 722
732.
185. Yang HW, Huang YF, Chou MY. Occurrence of Porphyromonas gingivalis and Tannerella forsythensis in periodontally diseased and healthy subjects. J Periodontol 2004:
75: 10771083.
186. Yano-Higuchi K, Takamatsu N, He T, Umeda M, Ishikawa
I. Prevalence of Bacteroides forsythus, Porphyromonas
gingivalis and Actinobacillus actinomycetcomitans on
subgingival microflora of Japanese patients with adult and
rapidly progressive periodontitis. J Clin Periodontol 2000:
27: 597602.
187. Zambon JJ, Grossi SG, Machtei EE, Ho AW, Dunford R,
Genco RJ. Cigarette smoking increases the risk for subgingival infection with periodontal pathogens. J Periodontol 1996: 67: 10501054.
188. Zee KY, Samaranayake LP, Attstrom R. Predominant
cultivable supragingival plaque in Chinese rapid and
slow plaque formers. J Clin Periodontol 1996: 23: 1025
1031.
187

Periodontal Microbial Ecology

Uploaded by

Copyright:

Available Formats

Periodontal Microbial Ecology

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Periodontal Microbial Ecology

Uploaded by

Copyright:

Available Formats

Copyright Blackwell Munksgaard 2005

Periodontology 2000, Vol. 38, 2005, 135187

Periodontal microbial ecology

The authors have taken the liberty of presenting this

Principles of microbial ecology

Periodontology 2000 will be to define the assemblage

Habitat and niches

Socransky & Haffajee

elimination of an organism by physical means;

that a change in habitat such as the development of

Fig. 1. Hypothesized relationship between the addition of

inflammation would result in increased growth of

Periodontal microbial ecology

Factors limiting colonization

number of samples examined. The bar colors indicate

Socransky & Haffajee

a possibility, although alternative hypotheses are

The climax community

Periodontal microbial ecology

Current studies of oral microbial

Earth that potentially could have colonized the oral

term low dose doxycycline and various local agents

Socransky & Haffajee

receptors), the possible introduction of artificial

Detection and enumeration of bacterial

disease initiation or progression as the presence of

Periodontal microbial ecology

cultivate the organisms and identify the species by

samples in periodontal health and different states of

Table 1. Methods to determine microbial composition of oral samples

Can detect unrecognized

Studies of new ecosystems

Few useful selective media

Studies of limited scope

Immunofluorescence Specificity; reasonably

Limited number of useful

Maybe more useful for

Not quantitative (presence

Real time PCR

Comparatively slow; very

Studies where quantitation

Confined to species for which

Seeking a specific set of

Confined to species for which

Extremely expensive; extremely

Survey a range of species that

Socransky & Haffajee

numbers will be severely underestimated. For

quantitative data (until recently) (69, 95), but usually

Periodontal microbial ecology

concerns regarding their use are unjustified or can be

microbiology, including loss of viability of organisms

Socransky & Haffajee

The first component: microbial

microorganisms by boiling in NaOH. After neutralization,

subgingival biofilms in both periodontally healthy

Periodontal microbial ecology

dry weight of the samples was 1.6 0.8 and

Known species detected

T. medium, T. denticola, T. maltophilum