87 The Chinese Journal of Dental Research

residing in the dental plaque

3,4
. Hence, dental plaque has
been known to be a reservoir oI microorganisms since
the dawn oI microbiology. However, until the 1980s
it was assumed that microbes predominantly live in a
suspended phase. ThereIore, most studies on microbial
diseases and drug-resistance mechanisms were based on
this Iree-Iloating or planktonic` mode oI growth. This
concept would have inIluenced the genesis oI Koch`s
postulates, which assumed that a speciIic pathogenic
agent is accountable Ior a speciIic inIectious disease.
In its early days, dentistry embraced Koch`s postulates
and attempted to link speciIic pathogenic agents with
particular dental diseases, such as Streptococcus mutans
which was discovered by Clarke as early as 1924
5

with dental caries.
It is only as late as the 1970s that pioneering stud-
ies by Costerton and colleagues led to an understand-
ing oI the community liIestyle oI microorganisms in
nature
6
. Incidentally, dental plaque was one oI the Iirst
Iew samples used in these ground-breaking studies on
microbial bioIilms. Costerton and colleagues showed
that microbial cells adhere to the tooth surIace and Iorm
1
Department oI Oral Biosciences, Faculty oI Dentistry, The University
oI Hong Kong, Hong Kong, P.R. China.
2
Department oI Comprehensive Dental Care, Faculty oI Dentistry, The
University oI Hong Kong, Hong Kong, P.R. China.
Corresponding author: Dr L.P. SAMARANAYAKE, Department oI
Oral Bio-Sciences, Faculty oI Dentistry, The University oI Hong Kong,
Hong Kong, P.R. China. Tel: 852-2859-0480; Fax: 852-2547-6133;
E-mail: lakshmanhku.hk
Dental Plaque Biofilm in Oral Health and Disease
Chaminda Jayampath SENEVIRATNE
1
, Cheng Fei ZHANG
2
,
Lakshman Perera SAMARANAYAKE
1
Dental plaque is an archetypical biofilm composea of a complex microbial community. It is the
aetiological agent for mafor aental aiseases such as aental caries ana perioaontal aisease. The
clinical picture of these aental aiseases is a net result of the cross-talk between the pathogenic
aental plaque biofilm ana the host tissue response. In the healthy state, both plaque biofilm ana
aafacent tissues maintain a aelicate balance, establishing a harmonious relationship between
the two. However, changes occur auring the aisease process that transform this healthy
aental plaque into a pathogenic biofilm. Recent aavances in molecular microbiology have
improvea the unaerstanaing of aental plaque biofilm ana proaucea numerous clinical benefits.
Therefore, it is imperative that clinicians keep abreast with these new aevelopments in the fiela
of aentistry. Better unaerstanaing of the molecular mechanisms behina aental aiseases will
facilitate the aevelopment of novel therapeutic strategies to establish a healthy aental plaque
biofilm by moaulating both host ana microbial factors. In this review, the present authors aim
to summarise the current knowleage on aental plaque as a microbial biofilm ana its properties
in oral health ana aisease.
Key words: aental plaque biofilm, health ana aisease, properties
Dental plaque biofilm - historical aspects
The relationship between microorganisms and dentistry
dates back to the earliest observations oI microorgan-
isms. In a letter to the Royal Society in September 1683,
Antoni van Leeuwenhoek described his observation oI
white little matter between his teeth` as an unbeliev-
able great company oI living animalcules, a-swimming
more nimbly than any I had ever seen up to this time, the
biggest sort bent . their body into curves in going Ior-
wards`
1,2
. Later studies revealed that the biggest sort`
he reIerred in his letter could be Selenomonas species
88 Volume 14, Number 2, 2011
SENEVIRATNE et al
a microbial community, as opposed to the common
notion at that time that microbes live as Ireely Iloating
organisms in suspensions. It is now widely accepted
that most, iI not all, microorganisms in nature preIer-
ably live as surIace adherent microbial communities
or bioIilms`
7
. More importantly, it has been revealed
that at least 65 oI all inIectious diseases are linked
to the bioIilm mode oI growth oI microbes, including
otitis media and cystic Iibrosis, and dental diseases
such as dental caries and periodontal disease
8
. BioIilm
microbes display phenotypic characters that are dra-
matically diIIerent Irom their planktonic counterparts
9
.
Higher drug resistance is one oI the notable Ieatures oI
the bioIilm mode oI growth
10
. BioIilms are spatially
arranged, well-organised microbial communities that
display properties as a unit. Hence bioIilm microorgan-
isms exhibit social` Ieatures, as opposed to the sum
oI individual Ieatures in the community. ThereIore, an
understanding oI microbial bioIilms provides us with
a clearer view oI their role in oral health and disease.
Formation and structure of dental plaque biofilm
All surIaces oI the human body that are exposed to the
exterior, such as the oral cavity, skin and gastrointestinal
tract, are colonised with resident microbiota
11
. How-
ever, each oI these habitats harbours a unique group oI
microbes, with properties that are diIIerent Irom those oI
the other habitats. Oral microbiota is distributed in strati-
Iied squamous oral mucosal surIaces, tooth surIaces and
muco-gingival margins.
Dental plaque is an archetypical bioIilm composed
oI a complex microbial community
12,13
. The National
Institutes oI Health initiated the Human Oral Microbiome
Database, based on 16S rDNA gene sequencing tech-
niques, to obtain a holistic view oI the dental plaque
bioIilm as conventional culture-based techniques had
only limited success in recovering plaque microbiota
14
.
Use oI the metagenomics approach has indicated that
the number oI bacterial species in the mature dental
plaque bioIilm could be as high as 19,000
15,16
. It is also
noteworthy that the composition oI the dental plaque
bioIilm is highly diverse between individuals and these
subtle diIIerences may generate a unique Iingerprint Ior
each individual
17,18
. However, under certain conditions,
shiIts in the composition and properties oI the dental
plaque bioIilm could lead to dental diseases, such as
dental caries and periodontal diseases. It is important
that clinicians are aware oI advances in the Iield oI den-
tal plaque bioIilm which could be used in the develop-
ment oI new treatment options in the Iuture. ThereIore,
in this brieI review the present authors examine the
structure and properties oI dental plaque bioIilm and
critically evaluate the dynamic relationship between
bioIilm and host in terms oI oral health and disease.
The adherence oI microbes to an oral surIace is a
prerequisite Ior the Iormation oI dental plaque bioIilm.
However, simple surIace contact or sedimentation oI
microbes does not lead to the Iormation oI a bioIilm.
Instead, a highly organised sequence oI events must
occur
12,19
(Fig 1). First, planktonic microorganisms
adhere to the surIace. Then, multiplication oI bacter-
ia leads to the Iormation oI discrete colonies. These
microcolonies secrete extracellular polymeric substance
(EPS) in which they become embedded, resulting in
the development oI bioIilm. EPS is a distinctive Iea-
ture seen in microbial bioIilm and provides a physical
scaIIold Ior the bioIilm community. Moreover, EPS
also contains biologically active components, such as
antimicrobial enzymes that protect the bioIilm com-
munity against noxious environmental stimuli. In a later
stage oI development, microcolonies embedded in EPS
S U R F A C E
nitial
colonisers
Secondary Colonisers
Adhesion + Cohesion
Mature
biofilm
EPS
production
Adhesion
Adhesion
Detachment
Detachment of
biofilm fragments
Fig 1 Sequence of biofilm development. A
biofilm typically develops in four sequential
steps: first, adhesion of a microorganism to
a surface; second, individual colonisation
and organisation of cells; third, secretion of
EPSs and maturation into a three-dimen-
sional structure; and finally, dissemination of
progeny biofilm cells. (Reprinted with the per-
mission of Oral Diseases, Blackwell Munks-
gaard).
89 The Chinese Journal of Dental Research
SENEVIRATNE et al
become linked together in an organised manner, leading
to Iormation oI a three-dimensional, spatially arranged
mature bioIilm community
20
.
A similar sequence oI events can be observed in the
Iormation oI dental plaque bioIilm. A cleaned tooth
surIace immediately comes into contact with bacter-
ial and host products in saliva and gingival crevicular
Iluid. These products are absorbed into the negatively
charged hydroxyapatite tooth surIace, making a thin
layer oI conditioning Iilm called acquired pellicle`.
This layer is covered in the supra-gingival areas by
positively charged molecules, such as salivary glyco-
proteins, statherin, histatin, proline-rich proteins and
alpha-amylase, and by products Irom gingival crev-
icular Iluid in the sub-gingival areas
21
. Some bacterial
components, such as glucosyltransIerases (GTFs) and
glucan, have also been Iound in the acquired pellicle.
Interestingly, the principal composition oI acquired
pellicle in diIIerent areas oI the oral cavity and between
individuals seems to be remarkably consistent. Gram-
positive streptococci such as Streptococcus sanguinis,
Streptococcus oralis, Streptococcus mitis and Neisseria
species are the primary colonisers oI the tooth surIace.
The negatively charged cell wall surIace oI the bacteria
Iacilitates their binding to the positively charged recep-
tor molecules on the pellicle. These primary colonis-
ers initially make non-speciIic, reversible long-range
(~50 nm) van der Waals bonds with the molecules
in acquired pellicle
11,12
. Subsequently they develop
stronger, irreversible short-range (1020 nm) adhesion
with receptors in the acquired pellicle using their cell
surIace adhesion molecules. Streptococcal group oral
bacteria have various adhesion mechanisms, such as
GTFs, glucan-binding proteins and pili, whereas other
bacteria such as Actinomyces uses their Iimbriae to
adhere to the surIace
22
.
Following adhesion oI the Iirst layer oI primary
colonisers, dental plaque bioIilm continues to build
up by multiplication oI the primary colonisers, and
by coaggregation and coadhesion oI secondary colo-
nising bacteria. A speciIic set oI secondary colonis-
ers with the propensity to attach to the receptors oI
primary colonisers are Iavoured over the organisms
that do not possess those properties. Development oI
dental plaque bioIilm reIlects the natural succession
oI niche-speciIic microorganisms. Primary colonisers
oI the dental plaque are either aerobic or Iacultative
aerobes, such as the streptococcus and Iusobacterium
groups oI bacteria. These reduce the oxygen, allowing
anaerobic bacteria to enter the bioIilm community as
secondary colonisers. Secondary colonisers are mainly
Gram-negative species such as Actinomyces species,
Fusobacterium nucleatum, Prevotella intermeaia and
Capnocytophaga species. It has been shown that coag-
gregation may occur between Gram-positive species,
such as S. sanguinis and Actinomyces; between Gram-
negative species, such as Prevotella melaninogenica
and F. nucleatum; and between Gram-positive and
Gram-negative species, such as Streptococcus and
Fusobacterium, respectively. Some speciIic structural
Ieatures in dental plaque bioIilm, such as corn cob`
and test-tube brush` appearance, can be observed due
to adherence oI cocci to Iilamentous bacteria. Recent
studies have Iurther conIirmed the corn-cob appearance
using the species-speciIic Iluorescent in situ hybridisa-
tion (FISH) technique
23
. At this stage oI development,
plaque bacteria secrete EPS, which Iorms the scaIIold
Ior the dental plaque bioIilm.
II dental plaque bioIilm is leIt undisturbed Ior
approximately 7 days the local environment rap-
idly changes, Iavouring colonisation by some Gram-
negative anaerobic bacterial species known as tertiary
colonisers`. These are mainly strict anaerobes which
opportunistically exploit the environment provided
by other bacteria. Tertiary colonisers include patho-
genic bacteria such as Porphyromonas gingivalis and
Aggregatibacter actinomycetemcomitans and spiro-
chetes such as Treponema aenticola. P. gingivalis has
been shown to coaggregate with Iacultative aerobic
bacteria such as Neisseria species as a survival strategy.
However, as mentioned earlier, advanced sequencing
techniques have redeIined the traditional understand-
ing oI the dental plaque as a microbial bioIilm. One
example is the Iinding oI TM7, an uncultivable bacte-
rial phylum which could be associated with periodontal
disease, in the dental plaque bioIilm
24,25
.
Maturation is an important property oI a bioIilm. It is
believed that, within a given environment, the bioIilm
community acquires the greatest stability with respect
to both time and space during the maturation stage.
In vitro studies on both single species and multiple
bioIilms have shown that maturation could occur by
24 to 72 hours, depending on the species and envi-
ronmental conditions. However, it is rather diIIicult to
determine the maturation oI in vivo bioIilms due to the
highly dynamic environment with complex interactions
between host and bioIilm. It is generally assumed that
dental plaque bioIilm matures` by 72 hours, although
this timing could be altered by Iactors such as dietary
intake or immunity oI the host.
Although development oI dental plaque generally
Iollows the aIorementioned sequence oI events, there
is huge variability in this process between individu-
als, even under healthy conditions. In a recent study
90 Volume 14, Number 2, 2011
SENEVIRATNE et al
by the present authors, diIIerences in the ultrastructure
and morphology oI the dental plaque bioIilm were
Iound between slow plaque Iormers` and Iast plaque
Iormers`
26
. Other studies have also demonstrated that
considerable variation in dental plaque thickness can
be seen within individuals. One study reported similar
plaque thicknesses in the buccal region oI the maxilla
and mandible but thinner bioIilm on the palatal side
27
.
Dynamic processes oI synergism and antagonism
occur during development but, once established, dental
plaque bioIilm is considered to be in a state oI homeo-
stasis. ThereIore, mature dental plaque bioIilm acts
as a community or a unit, rather than as a sum oI the
properties oI individual bacterial members. Microbial
homeostasis oI the dental plaque is only disturbed iI
drastic changes occur in the immediate environment oI
the host, such as changes in dietary intake or changes
in immunity leading to invasion oI host tissues by bio-
Iilm bacteria. This initiates a pathological sequelae oI
inIection and concurrent host inIlammatory response,
representing a shiIt Irom healthy plaque bioIilm to a
pathogenic bioIilm`. Pathogenic dental plaque bioIilms
not only result in dental diseases, such as dental caries
and periodontal disease, but could also be involved in
diseases in the cardiovascular, respiratory, renal and
other systems.
Properties of dental plaque biofilm
One oI the intriguing Ieatures oI microbial bioIilm,
including dental plaque bioIilm, is its selI-sustaina-
bility. A microbial bioIilm community would survive
under highly challenging environmental conditions that
its planktonic counterparts would not. For instance, it
has been shown that the bioIilm mode oI growth allows
microbes to survive under nutrition-limited conditions
Ior a long period oI time. Similarly, microbial constitu-
ents oI the dental plaque bioIilm do not rely on the nutri-
tion taken by the host; they are sustained by establishing
Iood-chains` involving other members oI the commu-
nity. Growth oI the dental plaque bioIilm depends on
the nutrients derived Irom endogenous sources, such
as saliva and gingival crevicular Iluid, rather than the
exogenous Iood intake oI the host. ThereIore, a meta-
bolic product oI one organism may be an essential pri-
mary source oI nutrition oI another. For instance, acido-
genic bacteria such as Streptococcus, Lactobacillus and
Actinomyces produce lactate as a by-product oI their
carbohydrate metabolism. Other bacterial species, such
as Jeillonella and Propionibacterium, utilise lactate as
a carbon source, and by doing so convert lactate into
weak propionic acid, reducing the risk oI dental caries
28
.
Similarly, the menaquinone produced by Jeillonella and
Propionibacterium is vital Ior the synthesis oI vitamin
K, which promotes the growth oI bacteria such as Por-
phyromonas, Prevotella and Bifiaobacterium
28
. Another
example is the use oI thiamine and isobutyrate by spiro-
chetes, which is produced by Fusobacterium species in
the dental plaque bioIilm. We are only beginning to gain
an understanding oI the Iascinating and intriguing rela-
tionships among the microbial members oI dental plaque
bioIilm, which could certainly help us to devise better
strategies Ior modulating the plaque bioIilm towards a
healthy state.
A unique Ieature related to microbial bioIilm is higher
antimicrobial resistance, and this can be seen in dental
plaque bioIilm. There are studies that show microbes in
the dental plaque bioIilm community are more resistant
to commonly used antimicrobial agents than are cor-
responding planktonic counterparts. Several hypotheses
have been put Iorward to explain the higher antibiotic
resistance oI microbial bioIilms, such as altered meta-
bolic state, contribution oI extracellular matrix, higher
antioxidative capacities, diIIerential transcriptomic and
proteomics expression, and presence oI sleeping cells`
or persister cells
29-31
. However, the exact mechanism
by which bioIilm microorganisms acquire higher anti-
microbial resistance remains to be elucidated.
In vivo studies oI dental plaque have corroborated
these in vitro observations. A study on subgingival
bioIilm showed that the concentration oI antibiotics
required to inhibit bacteria in steady-state bioIilm could
be up to 250 times greater than would be required to
inhibit their planktonic mode oI growth. Furthermore,
the antibiotics tetracycline, doxycycline, minocycline,
amoxicillin, metronidazole or combinations such as
amoxicillin/clavulanate and amoxicillin/metronidazole
were ineIIective in eradicating a 7-day-old mature
dental plaque bioIilm
32
. Another study showed that, in
bioIilm, periodontal pathogen P. gingivalis could be 60
and 160 times more resistant to doxycycline and metro-
nidazole, respectively, than its planktonic counterpart
33
.
Misuse oI tetracycline may enrich the bacteria in the
dental plaque with broad-range antibiotic resistance
34
.
These studies demonstrate the relative lack oI eIIicacy
oI systemic antibiotic therapy Ior periodontal diseases
and emphasise the need Ior alternative methods Ior
control Ior dental plaque-related diseases.
Quorum sensing (QS) or communication between
bacteria` is an intriguing property oI microbial bioIilms.
QS works as a gatekeeper, controlling the growth oI
the microbial community by signalling to bacteria to
leave the bioIilm to Iind new habitats
35
. QS is mediated
by small molecules, such as competence stimulating
91 The Chinese Journal of Dental Research
SENEVIRATNE et al
peptide (CSP) and autoinducer-2 (AI-2), which are
involved in both intra- and interspecies communication
among members oI bioIilm consortia. CSP produced
by many streptococcal species is involved in a diverse
set oI biological activities, including bioIilm Iormation,
antimicrobial resistance, horizontal gene transIer and
acid tolerance oI dental plaque bioIilm
36,37
. AI-2 encod-
ed LuxS gene is produced during bacterial amino acid
metabolism and plays a key role in both interspecies
and intraspecies communication and expression oI viru-
lence Iactors
38
. For instance, S. oralis and Actinomyces
naselunaii Iorm proIuse bioIilms only when the two
organisms grow in co-culture, and this phenomenon
depends on luxS-encoded AI-2
39
.
When living as a microbial community in the bio-
Iilm, individuals tend to share their virulence traits
by gene transIer, particularly the antibiotic-resistance
genes located in conjugative plasmids and conjugative
transposons. Exchange oI genetic material by means oI
horizontal gene transIer and the presence oI pathogenic
islands provide strong evidence that bioIilm commu-
nities have co-evolved and share their strategies to
survive as a community. Not only do the bacteria share
the survival advantage, but co-adhesion also allows
them to elicit the maximum eIIect oI their pathogenic-
ity. A recent study showed that a member oI the dental
plaque bioIilm Jeillonella aispar could transIer Tn916,
a conjugative transposon, to Streptococcus species in
oral bioIilms
40
. PuriIied genomic DNA oI J. aispar
could also transIorm S. mitis to tetracycline resistance.
Another mutual relationship in dental plaque bioIilm
could be seen between P. gingivalis and F. nuclea-
tum
41,42
. The minimum dose required Ior P. gingivalis
to elicit pathogenicity was reduced by 1000-Iold when
the bacterium coexisted in the bioIilm with F. nuclea-
tum compared with the individual pathogenicity
43
.
These studies clearly show the synergistic advantages
provided by the bioIilm mode oI growth Ior establish-
ment and survival oI bacterial species within the dental
plaque bioIilm.
Although the current knowledge on dental plaque
bioIilm has come a long way, Irom the initial observa-
tions oI van Leeuwenhoek to the current investigations
using molecular microbiology, still the complex bio-
logical interactions in the bioIilm community are not
Iully demystiIied. ThereIore it is imperative to revisit
the role played by plaque bioIilm in oral health and
disease. The ecological plaque hypothesis proposed by
Marsh elegantly explained that dental diseases result
Irom ecological catastrophes in the local environment
and the resulting changes in the microbiota oI the dental
plaque bioIilm
12
.
Dental plaque biofilm in health
Healthy dental plaque bioIilm predominantly comprises
commensal, non-pathogenic microbial members. These
commensal members, however, are not mute counter-
parts. There is a continuous cross-talk between commen-
sal bacteria in the dental plaque and with host tissues,
such as gingiva, even in the healthy state. However, it
is a harmonious, mutually beneIicial relationship. The
host provides a colonisation surIace Ior the commensals
and the bacteria provide colonisation resistance` against
pathogenic and more harmIul organisms
44
. The beneIits
oI this relationship become evident under the circum-
stances seen in an antibiotic sore mouth, a state in which
suppression oI normal Ilora leads to overgrowth oI
opportunistic pathogens. Studies have shown that some
commensal bacterial species, such as Jeillonella species,
Streptococcus salivarius, S. sanguinis and Atopobium
parvulum, could indicate a healthy state oI the bioIilm,
although more studies are needed to veriIy this claim.
Interestingly, S. salivarius has been shown to inhibit
quorum sensing and bioIilm Iormation oI S. mutans,
which may provide some evidence oI its protective role
against dental caries
45
.
Commensal bacteria in the dental plaque contribute
to the development oI a normal immune system by
constantly providing a versatile set oI bacterial anti-
gens Ior the host`s innate immune system. Commensals
initiate signal cascades that converge the messages oI
tolerance, whereas pathogenic bacteria induce a strong
inIlammatory response oI the host. ThereIore, there is
a continuous production oI pro-inIlammatory cytokines
in the oral epithelial cells at a low level, which cause
expression oI E-selectin in the vascular endothelial
tissues and establishment oI an interleukin-8 chem-
okine gradient
46
. Hence, commensal bacteria elicit a
host innate immune response that places neutrophils
strategic ally alongside the subgingival plaque bacteria
and junctional epithelium.
Role of dental plaque in dental caries
The ecological plaque hypothesis suggests that changes
in the environment in the vicinity oI the dental plaque
bioIilm could lead to dental diseases, such as dental
caries and periodontal diseases
44,47,48
. Frequent intake
oI dietary sugars provides an opportunity Ior acidogenic
and aciduric bacteria in the dental plaque bioIilm, such
as S. mutans and Lactobacillus aciaophilus, to create a
persistent acidic environment, which results in a shiIt in
balance towards the demineralisation oI the tooth sur-
Iace
49
. Recent studies oI S. mutans bioIilms have shown
92 Volume 14, Number 2, 2011
SENEVIRATNE et al
that the bioIilm mode oI growth has greater tolerance
oI acidic stress, which could be as high as six orders oI
magnitude higher compared with the planktonic Iorm
oI bacteria
50
. Mature S. mutans bioIilm down-regulates
the main energy generating glycolytic pathway in order
to be acid tolerant. There is other evidence to suggest
that members oI the dental plaque bioIilm community
undergo phenotypic changes during health and disease.
Recent studies showed that S. mutans strains recovered
Irom caries-active and caries-Iree individuals diIIer in
sensitivity to host antimicrobial peptides. Genes associ-
ated with glucan (GtI) and Iructan (ItI) have been shown
to be diIIerentially expressed between the planktonic
and bioIilm bacteria. The ecological changes that occur
in the dental plaque bioIilm may thereIore contribute to
the disease process seen in dental caries.
Conversely, some studies have suggested that the
presence oI high numbers oI S. mutans in the dental
plaque is not suIIicient Ior the development oI dental
caries. ThereIore, it is assumed that the presence oI a
single species alone is not the initiating Iactor, but that
multiple cariogenic species, such as S. mutans, S. mitis,
Rothia, Actinomyces, Lactobacillus and Bifiaobacterium
bacteria and even Iungal species like Canaiaa (Fig 2),
could account Ior a bioIilm becoming cariogenic.
Interestingly, Iungal species such as Canaiaa albicans
have been shown to be capable oI causing occlusal
caries at a high rate in rats
51
. A recent study which used
in situ imaging techniques to examine the architecture
oI the dental plaque bioIilm on natural teeth demon-
strated that C. albicans could Iorm corn-cob structures
with streptococcal species in the supragingival plaque,
which may explain its important niche in the dental
plaque
23
. Tanner et al suggested Scaraovia wiggsiae,
a new cariogenic bacteria, could be associated with
dental caries
52
. ThereIore, one must not be conIined to
the traditional thinking that a single species is the sole
cause oI diseases such as dental caries.
Recent advances in the understanding oI the molecu-
lar microbiology oI dental plaque bioIilm have pro-
duced numerous clinical beneIits. One such example
is xylitol, which selectively inhibits the growth and
metabolism oI S. mutans. Clinical studies have shown
the incorporation oI xylitol into chewing gum to be
eIIective in reducing mutans streptococci and lower-
ing dental caries
53,54
. Conversely, some in vitro studies
using multispecies cariogenic bioIilm models have
demonstrated that xylitol and sorbitol might not be as
eIIective as claimed
55
. Use oI probiotic bacteria such as
Lactobacillus rhamnosus LB21 as a milk supplement
is another idea that has been proposed Ior controlling
dental caries
56
. However, some studies have shown
this might not be eIIective in controlling colonisation
oI cariogenic bacteria in the caries-active adolescent
57
.
Other strategies have been considered, such as the use
oI protease produced by early dental plaque bioIilm
colonisers to inhibit the colonisation oI S. mutans
58
.
However, the complete picture oI the dental plaque bio-
Iilm is still not Iully understood, which is the Achilles`
heel in the task oI Iinding a successIul solution to the
global epidemic oI dental caries.
Dental plaque biofilm in periodontal disease
The main Ieature oI periodontal disease is inIlamma-
tion oI the periodontal tissues in response to Gram-
negative pathogenic bacteria such as P. gingivalis and
spirochetes such as T. aenticola in the dental plaque bio-
Iilm
59
. According to the ecological plaque hypothesis, it
is assumed that secretion oI gingival crevicular Iluid is
increased in response to inIlammation oI the periodontal
tissues. This leads to a rise in the local pH above the
normal neutral value. It has been suggested that even a
minor rise in pH allows periodontopathic bacteria such
as P. gingivalis to overgrow and override other micro-
organisms in the dental plaque
60
. Porphyromonas gingi-
valis is a hemin-dependent bacterium that acquires hemin
Irom gingival crevicular Iluid
61
. Secretory protease/
hemagglutinins, such as gingipains, hemagglutinin B
and hemagglutinin C, also aid P. gingivalis in acquiring
hemin Irom erythrocytes. A rise in local hemin concen-
tration, due to increased gingival crevicular Iluid during
periodontitis, provides a competitive advantage to the
so-called red-complex bacteria, including P. gingi valis,
over other commensal bacteria. Interestingly, recent
studies have shown that P. gingivalis is able to shiIt its
lipopolysaccharide (LPS) structure Irom penta-acylated
Fig 2 Scanning electron micrograph showing mature Can-
dida albicans biofilm.
93 The Chinese Journal of Dental Research
SENEVIRATNE et al
lipid A to tetra-acylated lipid A structures depending on
the hemin concentration in the local environment
62
. This
could be a strategy that pathogenic P. gingivalis uses to
evade the human immune system as a tetra-acylated LPS
structure paralyses` the local cytokine network, giving
the bacterium an opportunity to invade the gingival tis-
sue
63
. In addition to LPS, other virulent Iactors, such as
type IV Iimbriae oI P. gingivalis, could also contribute
to periodontal disease.
Intriguingly, this activity seems to be enhanced by
heavy smoking
64
. Other studies have also shown that
smoking could shiIt the microbial composition oI den-
tal plaque bioIilm towards colonisation by periodontal
pathogens such as Tannerella forsythia, P. gingivalis, T.
aenticola, P. intermeaia, Parvimonas micra, Prevotella
nigrescens and Campylobacter rectus
65,66
.
Changes in microbiota in supra- and subgingival
samples during in vivo development oI dental plaque
have been examined by several studies. Uzel et al stud-
ied the early developments that occurred in subgingival
dental plaque bioIilm in periodontally healthy and
chronic periodontitis subjects who reIrained Irom oral
hygiene
67
. Within 2 days, microbial Ilora was re-estab-
lished in the early dental plaque akin to that oI the pre-
cleaning state. Only subtle diIIerences could be seen
between the supragingival plaque oI healthy and peri-
odontally diseased subjects. Conversely, redevelopment
oI subgingival plaque was markedly diIIerent between
the two groups; dental plaque was more rapidly Iormed
in the latter compared with the healthy group.
Although the association oI red-complex bacteria
with periodontitis has been generally accepted by the
scientiIic community, neither the exact role played by
each bacterium nor the mechanism involved has been
Iully elucidated. Some studies have suggested other
bacterial species are also involved in the pathogen-
esis oI periodontal disease, complicating the already
complex picture oI pathogenesis. For instance, some
studies have shown that Selenomonas, which was Iirst
described by van Leeuwenhoek, may have an associ-
ation with periodontal disease
68
.
Summary
In view oI the Ioregoing inIormation, it seems appropri-
ate to conclude that the clinical picture oI dental disease
is a net result oI an interaction between the pathogenic
dental plaque bioIilm and the host tissue response. In the
healthy state, both plaque bioIilm and adjacent tissues
maintain a delicate balance and a harmonious cross-
talk is established between the two counterparts. Recent
advances in molecular microbiology have improved the
understanding oI dental plaque bioIilm and produced
numerous clinical beneIits. ThereIore, it is imperative
that clinicians keep abreast with these new developments
in the Iield oI dentistry. Better insights into the molecu-
lar mechanism behind dental diseases will Iacilitate the
development oI novel therapeutic strategies to establish
a healthy dental plaque bioIilm` through modulating
both host and microbial Iactors.
Acknowledgements
This work was partially supported by HKU Seed Fund-
ing Grant 201007159003 Ior CJS.
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