oo ORAL SURGERY

Vol. 94 No. 3 September 2002

o ORAL MEDICINE
ORAL PATHOLOGY

REVIEW ARTICLE

Endodontic infections: Concepts, paradigms, and perspectives

José F. Siqueira, Jr, DDS, MSc, PhD,a Rio de Janeiro, Brazil
ESTACIO DE SA UNIVERSITY AND FEDERAL UNIVERSITY OF RIO DE JANEIRO

Overwhelming evidence indicates that periradicular diseases are infectious disorders. The question now is no
longer whether microorganisms are involved in the pathogenesis of such diseases, but which specific microbial species
are. The list of microorganisms involved in periradicular diseases keeps expanding and has the potential to become
increasingly more accurate during the next few years. Molecular methods have contributed significantly to the
knowledge about the microbial species involved. Undoubtedly, a great deal of additional research is needed to define
the specific role played by suspected endodontic pathogens in the etiology of each form of periradicular disease and
to determine the best therapeutic measures for the pathogen’s eradication. In addition, there is an emergent need to
define markers that permit the clinician to know when he or she should conclude the treatment and to predict the
outcome of the treatment. Although endodontic procedures and some acute endodontic infections can cause
bacteremia, there is no clear evidence that microorganisms from the root canal can cause diseases in remote sites of
the body. However, there is a risk in some compromised individuals, and prophylactic measures should be taken.
Prescription of systemic antibiotics in endodontic therapy is rarely necessary. Because of the emergence of bacterial
resistance against most known antibiotics, their use in endodontics should be highly limited and restricted to a few
cases. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:281-93)

Although chemical and physical factors can induce bacterial species can reach and establish themselves at
periradicular inflammation, overwhelming evidence in- the periradicular tissues. Thus, although the original
dicates that microbial agents are essential to the pro- source of infection is not eliminated by the host defense
gression and perpetuation of periradicular inflamma- mechanisms, the host mounts a defense response adja-
tory diseases.1-4 The infected root canal constitutes the cent to the apical foramen, impeding the spreading of
main source of persistent microbial irritation to the the infection. Equilibrium between aggression and de-
periradicular tissues. fense is generally obtained, which results in the devel-
Microorganisms are located in privileged and strate- opment of a chronic inflammatory disease in the tissue
gic positions within the root canal containing necrotic around the portals of exit of bacteria. If the endodontic
pulp tissue. In such locations, they are protected from infection is effectively eradicated during endodontic
the action of host defense cells (phagocytes) and mol- treatment, the host is favored and tissue reparation
ecules (antibodies, complement). On the other hand, the ensues.
microbiota located at the apical part of the root canal The knowledge about endodontic infections has in-
system is usually delineated from the inflamed perira- creased significantly during the last 30 years, but sev-
dicular tissues either by a dense accumulation of poly- eral questions still await elucidation. The purpose of
morphonuclear neutrophils or by an epithelial plug at or this article is to review concepts and to discuss some
near the apical foramen.5 In rare circumstances a few current paradigms regarding endodontic infections, tak-
ing into account several aspects from the causal rela-
a
Chairman, Department of Endodontics, School of Dentistry, Estácio tionship between certain microbial species and the
de Sá University, Rio de Janeiro, and Associate Researcher, Institute periradicular diseases to the use of systemic antibiotic
of Microbiology, Federal University of Rio de Janeiro. therapy to treat infections of endodontic origin. There
Received for publication Nov 14, 2001; returned for revision Jan 28, are several gaps in knowledge that permit some spec-
2002; accepted for publication Apr 15, 2002.
© 2002, Mosby, Inc.
ulations, uniquely on scientific basis. The reader should
1079-2104/2002/$35.00 ⫹ 0 7/15/126163 be cautioned that gaps in knowledge may alter a few
doi:10.1067/moe.2002.126163 but certainly not all of the viewpoints expressed herein.

281
282 Siqueira ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
September 2002

ESTABLISHING CAUSAL OR CASUAL tection of uncultivable microbial pathogens, such as

RELATIONSHIPS Tropheryma whippelii, the causative agent of Whip-
For more than a century, Koch’s postulates have ple’s disease.9
been widely used to establish the causal relationship 3. Koch’s postulates imply that all strains of a given
between a given microbial species and a certain infec- microbial species are equally virulent. Today, it is
tious disease. The great contribution of Koch’s postu- known that different strains within a species vary in
lates was that they served as guidelines in an attempt to virulence.10-12
establish a standard for evidence of causation in infec- 4. Koch’s postulates suggest that only a single species
tious disease. The standard was intended to convince causes each disease. There are some diseases, such
skeptics that microorganisms can cause disease and to as periradicular diseases, that are induced by a mix-
create rigorous criteria to establish the etiologic agent ture of different microbial species.
of a given disease. 5. Koch’s postulates require that the suspected micro-
Koch’s postulates can be summarized as follows organism, after reinoculation into an animal, pro-
from his presentation before the 10th International Con- duce the signs and symptoms of the disease. Several
gress of Medicine in Berlin in 18906: human pathogens either do not cause the disease in
1. The microorganism occurs in every case of the animals or cause a disease with different character-
disease in question and under circumstances that can istics from the human form of the disease.10,13
account for the pathologic changes and clinical Current scientific thought recognizes that it is not
course of the disease. entirely possible and perhaps not required to fulfill
2. The microorganism occurs in no other disease as a every Koch’s criterion for evidence of causation to
fortuitous and nonpathogenic parasite. consider a microorganism a pathogen in a given infec-
3. After it is isolated from the diseased host and grown tious disorder.
in pure culture, the microorganism can induce the Several modifications of Koch’s postulates or even
disease anew. new criteria have been proposed to establish the micro-
A fourth postulate consisting of a requirement to bial causation of infectious diseases. Socransky and
reisolate the microorganism from the experimentally Haffajee14,15 have proposed some criteria to establish
inoculated host was added. This fourth condition ap- the causal relationship between microorganisms and
pears not to have been proposed by Koch.6 periodontal diseases. Most of their criteria might be
By using his recently developed technology and his applicable to endodontic infections.
criteria, Koch established bacterial etiology for anthrax,
tuberculosis, and wound infections. However, even Association
Koch was aware of the shortcomings of his criteria, and The suspected pathogen should be found more fre-
he did not believe that every postulate should be ful- quently and in higher numbers in cases of the infection
filled to prove disease causation.6 Koch had some prob- than in individuals without overt disease or with dif-
lems with his own criteria in his studies of cholera. In ferent forms of disease. Whereas in periodontal dis-
addition to being isolated from patients both with and eases researchers must distinguish pathogens within a
without cholera, Vibrio cholerae failed to experimen- normal microbiota, in endodontic infections this prob-
tally induce the disease in animals. Therefore, the lim- lem does not exist because the root canal system does
itations of Koch’s postulates were already evident in not possess a normal microbiota. As long as the pulp is
the 19th century. The main limitations of the postulates vital, it is a sterile tissue as any connective tissue
are the following: elsewhere in the body. Infection occurs only after pulp
1. Koch’s postulates place considerable emphasis on necrosis. Theoretically, any microbial species coloniz-
pathogenicity, which resides particularly in the mi- ing the necrotic pulp might participate in the pathogen-
croorganism. However, dependence on the host sus- esis of periradicular diseases. However, it appears that
ceptibility is an unquestionable issue. not all species present in endodontic infections are able
2. Koch’s postulates emphasize the ability to cultivate to cause disease.16-20 Current evidence suggests that a
the causative microorganism in pure culture. There restricted set of microbial species is more prevalent in
are some diseases, such as syphilis and leprosy, for different forms of periradicular diseases.3,21-41 This as-
which the causative bacterium has not yet been sociation suggests a pathogenetic role.
cultured in laboratory artificial media. It is currently
assumed that most of the bacteria living on earth are Elimination
impossible to culture.7,8 The oral cavity is not an The elimination of a species should be accompanied
exception. Recently, culture-independent molecular by a parallel remission of disease. One should try to
approaches have allowed the identification and de- eliminate the suspected pathogen, even when it is oc-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Siqueira 283
Volume 94, Number 3

curring in mixed infections, from root canals associated tative endodontic pathogens by subcutaneous inocula-
with periradicular lesions and determine whether the tion in small animals,18-20 a few studies have evaluated
disease resolves. This approach might be of great in- the pathogenicity of such species and their combina-
terest. However, this criterion has certain problems in tions by inoculation into root canals of animals.16,17
that endodontic therapy never eliminates only 1 species Results from both study designs have supported that a
at a time. In some cases, species not eliminated by selected group of microorganisms are potential end-
endodontic therapy can lead to treatment failure. How- odontic pathogens.
ever, although several cases of endodontic failure have
been associated with a restricted group of species, in Risk factor analysis
which Enterococcus faecalis is the most preva- Technological developments can permit the develop-
lent,28,29,36 there are several other cases of failure in ment of prospective studies in which the risk of disease
which these species were not present or remained un- progression conferred by the presence of a microorgan-
detected. ism at given levels may be assessed. This criterion is
applicable only to experimental root canal infections in
Host response animal models. There is a paucity of information re-
If a microbial species gains access to connective garding this issue. Animal studies have shown that
tissues and causes damage, it seems likely that the host there is a shift in the root canal microbiota from pre-
will mount a specific immunologic response, producing dominantly facultative during the first days to increas-
antibodies or a cellular immune response that is di- ingly Gram-negative and anaerobic after a short period
rected specifically at that species. A few studies have of time (from weeks to months).48,49 These changes
reported the production of specific antibodies against a were reported to occur during the period of rapid lesion
number of putative endodontic pathogens in periradicu- expansion.49 Results from these studies have indicated
lar lesions.42,43 This indicates that the host mounts a that a restricted set of species is implicated in the
humoral immune response against specific microorgan- pathogenesis of periradicular lesions.
isms colonizing the root canal system. Although the Although no single microorganism or a specific mi-
occurrence of a cellular immune response in periradicu- crobial mixture has fulfilled all Koch’s or Socransky’s
lar lesions has been demonstrated,44 there are no eluci- criteria, results from studies in different geographic
dative reports regarding its specificity against putative locations suggest that the presence of a restricted group
endodontic pathogens. of microbial species in a consortium is associated with
the pathogenesis of periradicular diseases (Table). At
Virulence the moment, it is highly likely that no single species
Virulence factors may also provide valuable clues to will be discovered to be the “major” endodontic patho-
pathogenicity. Potentially damaging products released gen. Even advanced molecular techniques have failed
or properties possessed by certain species may be sug- to detect a single species involved in all cases of infec-
gestive that the species could play a role in disease tion or at least in all cases of a particular form of
process. Putative endodontic pathogens have a potential periradicular disease. Thus, a key criterion in both
array of virulence factors, but if they produce these Koch’s and Socransky’s postulates, association in its
factors in vivo, it is still unknown. Studies have re- absolute sense, is not yet fulfilled by any microbial
ported the detection of virulence factors within infected species and probably will never be. However, the ful-
root canals, including lipopolysaccharide, enzymes, fillment of other important criteria has been reached by
and metabolites, and have associated them with signs a limited number of microbial species, which have been
and symptoms of disease.45-47 However, which species more frequently found in infected root canals. Most of
within the root canal specifically produced those factors these species are potentially pathogenic, particularly in
has not been elucidated. mixed infections, and may be implicated in the patho-
genesis of other human diseases, mainly in the oral
Animal pathogenicity cavity. Therefore, frequently detected species may be
Experimentally induced disease in animals, such as considered as suspected endodontic pathogens.
dogs and monkeys, can be manipulated to favor selec-
tion of single or subsets of species that may or may not MICROBIAL CAUSATION OF PERIRADICULAR
induce the disease. These models usually suggest a DISEASES
possible etiologic role of a species or a set of species in More than a century ago Miller50 wrote: “We as-
the pathogenesis of the animal’s disease that may have sume, in a general way, that bacteria must in some
some analogy in the human disease. Although there are manner be connected with these processes [pulp dis-
several studies that evaluated the pathogenicity of pu- eases]. . . There are, then, as I have already pointed out,
284 Siqueira ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
September 2002

Table. Genera of putative endodontic pathogens commonly associated with different forms of periradicular diseases
Primary infections
Chronic periradicular Acute periradicular Secondary and/or Extraradicular
lesion* abscess† persistent infections‡ infections§
Bacteroides Porphyromonas Enterococcus Actinomyces
Treponema Treponema Actinomyces Propionibacterium
Prevotella Fusobacterium Streptococcus
Porphyromonas Bacteroides Candida
Fusobacterium Prevotella Propionibacterium
Peptostreptococcus Streptococcus Staphylococcus
Streptococcus Peptostreptococcus Pseudomonas
Eubacterium
Actinomyces
Campylobacter

*References 3, 21, 23, 25, 26, 27, 30, 31, 34, 38, 52, 53, 82, 83, 84,85.
†
References 27, 30, 32, 33, 37, 41, 52.
‡
References 28, 29, 36, 40, 59.
§
References 22, 35.

different species of bacteria in the diseased pulp that Recent epidemiologic studies with molecular methods
have not yet been cultivated on artificial media, and of have found a relatively high prevalence of spirochetes
whose pathogenesis we know nothing definite. Their in infected root canals, particularly Treponema denti-
great numbers in some pulps, and especially the re- cola, which is also a putative periodontal patho-
peated occurrence of spirochaetes, justify the supposi- gen.30,33,34
tion that, under certain circumstances, they may play an Although Miller50 reported in 1894 the occurrence of
important role in suppurative processes.” bacteria in root canals with associated pathologic condi-
Most of his questions remained unanswered for tions, the causal relationship between microorganisms and
many decades. From the classic findings of Kakehashi periradicular diseases was only demonstrated in the
et al1 in 1965 to date, very important questions have 1960s.1 Through studies in monkeys and humans other
been resolved. Nonetheless, several aspects of the end- investigators confirmed microbial causation.3,4 The search
odontic infection are still confusing and need further for the specific etiologic agents of periradicular diseases
elucidation. has been in progress since then. Regardless of the diag-
Miller50 raised the hypothesis that bacteria are the nostic method used, epidemiologic studies have shown
causative factors of diseases of endodontic origin. At that more than 200 different microbial species can be
his time, he recognized that some bacteria from root found in infected root canals, usually in combinations of 4
canal samples that he had seen under light microscopy to 7 species per canal.21-41,51 Theoretically, any one of
were not able to be cultivated by using the technology these species would have the potential to be an endodontic
available at that time. Most of those bacteria were pathogen.
probably anaerobic bacteria. However, in spite of the Therefore, abundant evidence indicates that micro-
considerable technological advances during the last organisms play a primary role in the etiology of perira-
century regarding the culture of bacteria, it is assumed dicular diseases. The question then is no longer whether
that the great majority of microbial species living on microorganisms cause periradicular lesions, but rather
earth remain uncultivable.7,8 This might also be true for are specific microbial species responsible for specific
intracanal microorganisms. forms of periradicular diseases? In other words, what
We understand the major mechanisms of pathoge- theory better explains the causal relationship between
nicity of most known human pathogens, even though microorganisms and periradicular diseases, the nonspe-
there are still several microorganisms that are consid- cific microbiota hypothesis or the specific microbiota
ered as putative pathogens because of the fact that the hypothesis?
mechanisms of their pathogenicity are not completely Evidence suggests that a consortium, not a particular
understood. species, possesses the physiologic requirements neces-
Miller50 also suggested that spirochetes might be sary to cause damage to the periradicular tissues. In
important endodontic pathogens. After more than 100 addition, it is becoming apparent that different compo-
years, his theory remains to be proved, in part because sitions of the root canal microbiota can possess equal
of the difficulties to cultivate most spirochete species. ability to elicit tissue injury. This does not necessarily
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Siqueira 285
Volume 94, Number 3

represent a confirmation of the nonspecific hypothesis. strable array of virulence factors, at least in vitro and
Specific mixtures of species that are implicated in the ideally in vivo, if it is pathogenic in animal models, and
pathogenesis of periradicular diseases are still un- if it is implicated in the etiology of other human dis-
known, but it is conceivable that the most frequently eases, it can be considered a suspected endodontic
isolated species may make a major contribution to the pathogen. To date, our knowledge is limited to putative
ecology of the community colonizing the root canal endodontic pathogens.
system and consequently to the degree of pathogenicity
of the consortium. Some of these most prevalent spe- REQUIREMENTS FOR ENDODONTIC
cies, not all, exert an important role in pathogenicity PATHOGEN
and thereby act as key pathogens. The following requisites are required for a given
Although microbial load is important to pathogenic- microorganism to establish itself in the root canal sys-
ity, recent data from different laboratories have sug- tem and to further participate in the pathogenesis of a
gested that different forms of periradicular diseases periradicular disease:
may have specific microbial etiologies. Of the more 1. The microorganism must be present in sufficient
than 500 microbial species colonizing the oral cavity, numbers to initiate and maintain the periradicular
perhaps a restricted set of 15 to 30 species have been disease.
frequently detected in infected root canals and may be 2. The microorganism must possess an array of viru-
responsible for the majority of periradicular diseases in lence factors, which should be expressed during root
uncompromised humans. Other additional species may canal infection.
be implicated in diseases in a small percentage of the 3. The microorganism must be spatially located in the
cases. Particularly in failed cases, the number of mi- root canal system in such a way that it or its viru-
crobial species involved may be even smaller. This lence factors can gain access to the periradicular
indicates that the semispecific microbiota hypothesis is tissues.
the more coherent to explain the pathogenesis of perira- 4. The root canal environment must permit the survival
dicular diseases. Thus, some groups of bacteria are and growth of the microorganism and provide sig-
probably more involved in the etiology of some forms nals or cues that stimulate the expression of viru-
of periradicular diseases, usually composing a mixed lence genes.
consortium. 5. Inhibiting microorganisms must be absent or present
There are some difficulties in interpreting findings in low numbers in the root canal environment.
from prevalence studies. The major difficulties refer to 6. The host must mount a defense strategy at the
conceptual problems regarding mixed infections and periradicular tissues, inhibiting the spread of the
opportunistic microbial species. Opportunistic species infection. This process will result in tissue damage.
(not opportunistic pathogens!) may grow in the root Studying these requisites may provide evidence re-
canal system as a result of the pulp necrosis rather than garding the causal relationship between the suspected
being the cause of periradicular lesions. In these cases, microorganism and the periradicular disease.
they would be mere bystanders. In addition, environ-
mental conditions may allow the increase of opportu- TYPES OF ENDODONTIC INFECTION
nistic species. Therefore, their mere occurrence, some- There are different types of endodontic infections,
times in high numbers, makes them difficult to which are usually associated with different clinical
distinguish from pathogenic species. In addition, most conditions. The root canal infection is the primary
endodontic infections are mixed infections. It is ex- cause of acute or chronic periradicular diseases. Sec-
tremely difficult to evaluate the role of a single species ondary or persistent infections are the cause of second-
in the etiology of the periradicular diseases. It is even ary or chronic periradicular lesions, which can result in
more difficult to evaluate all possible pairs or larger persistent symptoms, exudation, or the failure of the
mixtures of species. Imagine the number of possible endodontic treatment.51 The composition of the micro-
combinations between 2 or more species of all sus- biota varies depending on the types of infection and
pected pathogens that should be tested for pathogenic- periradicular lesions (Table I).
ity!
The reported high prevalence of a given microbial Primary root canal infection
species does not necessarily ensure a causal relation- Primary root canal infection is caused by microorgan-
ship between the species and the etiology of the perira- isms colonizing the necrotic pulp tissue. The involved
dicular disease. This mainly indicates that the microbial microbiota usually shifts depending on the time of infec-
species is successful in colonizing the root canal sys- tion. Moreover, it has been strongly suggested that the
tem. If the highly prevalent species produces a demon- microbiota can differ according to the type of periradicular
286 Siqueira ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
September 2002

diseases. Whereas a wide range of microbial species is The microbiota associated with persistent secondary
associated with chronic periradicular lesions, a more re- infections is usually composed of a single species or at
stricted group of species is associated with symptomatic least by a lower number of species when compared with
periradicular diseases such as acute apical periodontitis primary infections. Gram-positive bacteria are the pre-
and acute periradicular abscess.21-27,30-35,37-41 dominant.28,29,36,59 Fungi can also be found at signifi-
In general, primary infections are mixed and pre- cantly higher rate than in primary infections.36,40,60
dominated by anaerobic bacteria. Predominant species
usually belong to the genera Bacteroides, Porphyromo-
Extraradicular infection
nas, Prevotella, Fusobacterium, Treponema, Pep-
tostreptococcus, Eubacterium, and Campylobacter. Extraradicular infections may also be primary, sec-
Facultative or microaerophilic streptococci are also ondary, or persistent. The most common form of ex-
commonly found in primary infections. traradicular infection is the acute periradicular abscess.
Current evidence suggests that some Gram-negative The source of extraradicular infections is usually the
anaerobic bacteria are closely associated with the eti- intraradicular infection. Extraradicular infection is a
ology of symptomatic periradicular lesions, including rare occurrence.
cases of acute periradicular abscess.3,23-25,27,32,37,41 Nev- A considerable interest has lately been generated
ertheless, the same species commonly found associated regarding the potential role of extraradicular persistent
with symptoms have also been observed in asymptom- microorganisms in the failure of the root canal treat-
atic cases.23,25,26,31,32,52,53 Some factors can explain ment. Cultural, molecular, and microscopic studies
these findings. Strains of putative pathogens may differ have reported the occurrence of extraradicular micro-
in virulence. Such differences can be one of the expla- organisms either in treated or in untreated endodontic
nations why some species are found in both symptom- cases.22,35,61-67 Because microorganisms established in
atic and asymptomatic cases. The presence of other the periradicular tissues are inaccessible to endodontic
species in a mixed community acting in synergy and disinfection procedures, extraradicular infection may
differences in the number of bacterial cells are other cause the failure of the endodontic therapy.
possible explanations. Other important factors that have A few oral microorganisms have the ability to over-
not been taken into account are the environmental con- come host defense mechanisms and thereby induce an
ditions and the host resistance. Recent evidence indi- extraradicular infection. It is currently recognized that
cates that bacteria can change their behavior and hence some oral microorganisms, such as Actinomyces spe-
become virulent because of environmental stresses gen- cies and Propionibacterium propionicus, may be im-
erated by conditions such as starvation, population den- plicated in extraradicular infections.22,35,63,67 Some
sity, pH, temperature, and iron availability.54-57 strains of other putative oral pathogens have also been
detected in chronic periradicular diseases by culture
Secondary root canal infection and molecular studies.61,63-66 However, their involve-
Secondary intraradicular infections are caused by ment in an extraradicular infectious process is not clear.
microorganisms that were not present in the primary In fact, these are very intriguing findings because most
infection and have penetrated the root canal system of the detected species are usually oral opportunistic
during treatment, between appointments, or after the pathogens that normally cannot survive in such hostile
conclusion of the endodontic treatment.51 If the pene- environment. It is unclear whether a mixed infection
trating microorganisms are successful in surviving and composed of several species can regularly establish
colonizing the root canal system, a secondary infection itself in the periradicular lesion. A recent study68 with
is established. scanning electron microscopy showed that a very small
percentage of the untreated teeth associated with perira-
dicular lesions showed evidence of extraradicular in-
Persistent root canal infection
fection, which is congruent with the high success rate
Microorganisms that in some way resisted the intra-
of the nonsurgical endodontic treatment.
canal procedures of disinfection cause persistent in-
traradicular infections. Causative microorganisms were
members either of the primary infection or of a second- MECHANISMS OF MICROBIAL
ary infection. PATHOGENICITY
Environmental influences operate in the root canal Establishment within a suitable site is essential for
system during and after treatment, which may select survival of the microorganism and the optimal biologic
certain microorganisms to survive. Therefore, the few activity within the environment.
microbial species that have such ability may be in- Many host protective mechanisms against microbial
volved in the failure of the root canal treatment.58 colonization are not present in the restricted root canal
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Siqueira 287
Volume 94, Number 3

environment. Although attachment to surfaces may not as elastase, collagenase, and gelatinase, induce the de-
be an essential requirement for colonization, the micro- struction of the extracellular matrix, leading to the pus
organisms that possess the ability to attach to dentin formation.51 Therefore, bacteria can exert indirect de-
may have an ecologic advantage. structive effects, which seems to be more significant in
Invasion of the pulp only occurs after tissue necrosis. the tissue damage associated with acute and chronic
Therefore, the need for the bacteria to possess virulence periradicular lesions.
factors is minimal. This is demonstrated by the fact that More than likely, few of the putative endodontic
most of the oral microorganisms invading the necrotic pathogens are capable of inducing all of the events
pulp are opportunistic pathogens. involved in the pathogenesis of periradicular diseases.
Survival in the necrotic pulp tissue is initially not Probably the process requires an integrated and orches-
difficult for invading microorganisms because there are trated interaction of the selected members of the mixed
available nutrients but minimal host defense in this endodontic microbiota. To be considered a putative
environment. With time, selective pressures are oper- endodontic pathogen, the microorganism should pro-
ating in the root canal milieu and primarily consist of duce an array of virulence factors, which should ideally
oxygen tension, redox potential, pH, temperature, and be expressed in vivo, ie, in the root canal environment.
type of available nutrients. Only the microbial species As aforementioned, this remains to be illuminated.
that are able to adapt to the environmental conditions of In most cases, infection is restricted to the root canal.
the root canal system will be selected and establish Most of the microbial species that infect the root canal
themselves. Further microbial positive or negative in- are opportunistic pathogens and thereby do not have the
teractions will influence the ultimate composition of the ability to survive in the periradicular tissues, where the
root canal microbiota. host defense mechanisms are optimal. Rare exceptions
Periradicular disease will occur after microorgan- are those microbial species or even strains within a
isms and their metabolic products affect the periradicu- species that possess strategies to survive and thus to
lar tissues. The magnitude of the host response will be infect vital tissues. Such microorganisms must possess
directly proportional to the virulence and the number of the ability to invade tissues, scavenge nutrients, and
microbial cells present. evade the host defense mechanisms. If they are suc-
Tissue damage caused by bacteria is mediated by cessful in this regard, an extraradicular infection may
either direct or indirect mechanisms. Direct harmful develop.
effects caused by bacteria involve their products, such
as enzymes (collagenase, hyaluronidase, condroitinase, Genetic control of virulence and cell-cell
acid phosphatase), exotoxins and metabolites (butyrate, communication
propionate, ammonium, polyamines, indole, sulfured Microorganisms’ potential to induce disease is ge-
compounds).10 In addition, bacterial components, such netically determined and influenced by environmental
as peptidoglycan, teichoic acid, fimbriae, outer mem- factors. In a number of microbial species, virulence
brane proteins, capsule, and lipopolysaccharide, stimu- genes are found in large contiguous blocks in chromo-
late the development of host immune reactions capable somal DNA, termed pathogenicity islands. Pathogenic-
of causing severe tissue destruction.10,69,70 For exam- ity islands carry 1 or more virulence factors and are
ple, macrophages can be activated by bacterial compo- present in the genome (chromosome or plasmid) of
nents and can be stimulated to release chemical medi- pathogenic bacteria but absent from the genome of
ators such as cytokines (interleukin-1␤, tumor necrosis related nonpathogens. They range in size from 10 to
factor, and interleukin-6), and prostaglandins, which 200 kilobase and often have different G⫹C content,
are involved in the induction of bone resorption com- suggesting their acquisition by horizontal transfer of
monly observed in chronic periradicular diseases.69,70 DNA.13,55,57 Some virulence plasmids of certain bacte-
Recently, it has been demonstrated that bacterial DNA ria have been called an archipelago of pathogenicity
may activate macrophages and dendritic cells, trigger- islands and smaller elements (1 to 10 kilobase) islets.13
ing release of proinflammatory cytokines.71 Another Together with pathogenicity islands, phage insertions,
example refers to the tissue damage associated with the plasmids, and transposons provide the genetic bases of
acute periradicular abscess. Host defense mechanisms pathogenicity of many medical pathogens, and end-
against bacteria egressing from the root canal appear to odontic pathogens are probably no exceptions.
be the most important factor involved in pus formation Virulence depends on coordinated expression of sev-
associated with acute periradicular abscess. Formation eral genes whose products mediate many functions
of oxygen-derived free radicals, such as superoxide and such as attachment to host surfaces or other microor-
hydrogen peroxide, together with the release of lysoso- ganisms, the invading ability, the production of toxins
mal enzymes by polymorphonuclear neutrophils, such and enzymes, which can damage host tissues, and the
288 Siqueira ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
September 2002

capability to survive in a hostile environment by both These species are suspected endodontic pathogens. It is
evading host defense mechanisms and scavenging nu- entirely possible that other endodontic pathogens also
trients. Microorganisms can also express new gene produce autoinducers, and the possibility exists that
products in response to changing environments, which they are involved in adaptability to root canal environ-
enable themselves to modify their behavior and to ment and coordinate activity resulting in enhanced
survive during different stages of the infectious pro- pathogenicity. Most bacterial species infecting the root
cess.57 Because many virulence genes are encoded on canal system are nonmotile, so perhaps most signals
mobile genetic elements, they have the ability to spread communicate only microdistances. The precise role of
to other microorganisms, including nonpathogenic cell-cell communication mechanisms in the virulence
strains of the same or closely related species. of the root canal microbiota is an enigma.
Nearly all virulence factors are tightly regulated, Other stress conditions, such as starvation, may also
with their expression linked to diverse environmental be responsible for inducing the virulence apparatus in
signals. Some biochemical and physical parameters that certain pathogens.73,78 Living bacteria in nature com-
affect virulence factor regulation include starvation, monly experience periods of starvation. It is known that
population density, pH, temperature, iron availability, bacteria activate complex molecular regulatory mech-
oxygen tension, and redox potential. Hence, on receiv- anisms in response to starvation.73,78 Once starvation
ing the appropriate environmental signals or cues, dif- genes are expressed, bacteria shift their behavior to
ferent sets of virulence genes are turned on or off. This survive in conditions of nutrient depletion. The major
allows adaptation to different environmental condi- induced mechanisms include control of the energy gen-
tions. eration during starvation and enhancement of the scav-
Recently, intercellular communication among bacte- enging ability of the scarce nutrient. These mechanisms
ria has been demonstrated that results in collective may allow bacteria to survive in root-filled teeth and
behavior to enhance adaptation and defense. Intercel- induce endodontic failure even in seemingly well-
lular communication is based on autoinducers, a group treated cases.
of self-generated signal molecules. This phenomenon is Because most endodontic infections are mixed infec-
referred to as quorum sensing and has been described in tions, it is entirely possible that communication among
both Gram-positive and Gram-negative bacteria.57,72-75 genetically distinct microorganisms occurs. Neverthe-
Some bacteria use quorum sensing as part of their less, little is known about metabolic cooperation within
pathogenic lifestyle. With some Gram-negative patho- the infected root canal, about gene expression and
gens, expression of virulence genes may be the indirect cell-cell signaling among the components of the end-
result of bacterial growth and an increase of cell density odontic microbiota, or about the spatial organization of
to reach a quorum of cells. Some opportunistic patho- the different species within the consortium. Such
gens express virulence factors in response to sensing its knowledge may enhance the understanding of the
own cell density.72,76,77 During normal growth, bacte- pathogenesis of different forms of periradicular lesions,
rial cells may continually secrete autoinducers into the as well as clarify the specific role played by certain
environment. Low cell densities will release autoin- bacterial species. This knowledge may lead to new
ducer concentrations too low to be detected. However, therapeutic measures to control root canal infections.
when sufficient bacterial cells are present, autoinducers
can reach sufficiently high concentrations that allow the INVESTIGATION OF THE ENDODONTIC
bacteria to sense a critical cell mass and, in response, to MICROBIOTA BY MOLECULAR TECHNOLOGY
activate different sets of target genes that allow the Surveys of many terrestrial and aquatic ecosystems
bacteria to survive environmental changes. The use of indicated that more than 99% of microorganisms living
intraspecies and interspecies quorum sensing may on Earth resist cultivation under laboratory conditions
greatly enhance the chances of bacterial survival or and can only be identified or characterized with the use
may allow bacteria to build communities in which of molecular genetic methods.7,8,79 It is thought that
division of labor would grant the community numerous about 50% of oral bacteria have not yet been cultivat-
new properties and benefits. Because intercellular com- ed.80 During the past 15 years, several human diseases
munication not only occurs at high cell densities, the and associated microbial pathogens were first identified
term quorum sensing is now being used to describe any directly from clinical specimens by using molecular
bacterial intercellular communication that involves dif- approaches.
fusible signal molecules. Identification of infectious agents by phenotypic
Strains of Porphyromonas gingivalis, Fusobacterium traits has serious shortcomings, because it is often
nucleatum, and Prevotella intermedia were recently impossible to reproduce growth conditions required by
found to produce quorum sensing signal molecules.77 some microorganisms. Phenotypic traits are also diffi-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Siqueira 289
Volume 94, Number 3

cult to identify, because they may be ambiguous and HOST SUSCEPTIBILITY TO INFECTION AND
show divergent behavior. The valuable information re- ENDODONTIC FAILURES
garding human pathogens provided by phenotypic- Infectiousness is usually not the same as pathogenic-
based culture methods since Koch’s pioneer studies ity. Thus, host susceptibility to infection does not nec-
cannot be disregarded, but genotypic traits generally essarily implicate susceptibility to disease. An infection
provide more reliable and quantifiable information for can be totally harmless and asymptomatic in some hosts
identification and characterization of infectious but can cause severe damage in other hosts. It will
agents.6-8 Moreover, genotypic traits can be directly depend on results of the encounter between the micro-
assessed in clinical specimens, without the need for organism and the host. Therefore, some host and mi-
growth and isolation of the microorganisms involved. crobial factors decisively influence the susceptibility to
Many of the species in the infected root canals are disease. Most important microbial factors include ge-
difficult or impossible to grow, and others, such as netic factors of the microorganism such as control of
phenotypically divergent strains, are difficult to iden- virulence gene expression. However, some host factors
tify. Strains within a given cultivable species can also are usually not taken into account when one considers
show the same difficulties or impossibilities. the pathogenesis of periradicular lesions.
New technologies have been used to enhance our Genetic susceptibility of the host to infection may
operate at the level of the immune system, and there is
understanding of endodontic infections. Recent mo-
increasing evidence that this is an important phenom-
lecular studies have suggested that some anaerobic
enon.13 Hosts with genetic traits conferring a poor
bacteria are more prevalent in endodontic infections
immune response to certain microorganisms are likely
than previously shown by culture.27,52,81 In addition,
to have difficulty controlling infection caused by those
some other bacterial species that had never been
microorganisms. On the other hand, those with such a
isolated from infected root canals were detected by
poor immune response are less likely to suffer immu-
molecular techniques. This is the case for Bacte- nopathologic consequences of the infection.
roides forsythus30-32,82,83 and Treponema denti- Among the causes of increased susceptibility to in-
cola,30,33,34 which are recognized periodontal patho- fection, deficiencies in the immune response can be
gens.15 Other species such as Prevotella tannerae84 and considered as one of the more significant. People who
Treponema maltophilum85 were also detected in in- show less major histocompatibility complex polymor-
fected root canals for the first time after molecular phism can have great susceptibility to infections.13 Sus-
investigation. Further, uncultivable and unknown spe- ceptibility is generally greater in very young and very
cies have also been found in root canal infections.86 old individuals, who usually exhibit weaker immune
Therefore, molecular genetic approaches have con- responses.13 Severe nutritional deficiencies will inter-
tributed significantly to the knowledge of the root canal fere with several immune mechanisms and increase the
microbiota by allowing the recognition of new putative vulnerability to infections. Hormonal factors, stress,
endodontic pathogens and strengthening the association human immunodeficiency virus infection, use of immu-
of some cultivable but fastidious anaerobic bacteria nosuppressive drugs, and debilitating diseases (such as
with root canal infections. As all identification meth- diabetes and malignancies) can also influence the host
ods, molecular assays also have some shortcomings. response to infection.13
For instance, whole genomic probes used in DNA- Although no work has been discussing these factors,
DNA hybridization assays may show cross-reactivity the question remains whether patients with impaired
with nontarget microorganisms because of the presence host resistance are more susceptible to endodontic fail-
of homology between different bacterial species. ure. It is also possible that some lesions will take more
This can generate false positive results. In addition, time to heal in these patients.
most molecular assays have been used only to detect
target microbial species and consequently fail to BIOLOGIC MARKERS TO PREDICT
detect the unexpected. Some molecular assays give ENDODONTIC SUCCESS
nonquantitative results, which can make it difficult to Advances in knowledge about pathogenicity of
assess the role played by the microorganism in its periradicular lesions can also contribute to the devel-
environment. opment of a reliable biologic marker that would allow
Undoubtedly, the well-directed use of these methods the clinician to know the moment to conclude treatment
will provide additional valuable information regarding and to predict the outcome of the treatment.87 The
the identification and understanding of the causative bacteriologic test (culture) was a marker used for many
factors associated with endodontic diseases, helping to years in endodontics to indicate the end point of treat-
develop more successful treatment strategies. ment. Because of several shortcomings of the method,
290 Siqueira ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
September 2002

it is no longer used for this purpose. To develop a naturally as a result of normal daily activities. Some
reliable microbiologic marker may be a difficult task, individuals may generate bacteremia for 90 hours per
but the sampling procedure is another limiting factor. month from normal activities.97 The virulence and
Obviously, not even the most advanced diagnostic test number of oral microorganisms, the duration, and the
will detect a given microorganism or metabolic by- host predisposing factors are important factors when
products if they are absent from the sample. Therefore, assessing complications from bacteremia.
reliable sampling procedures must be found. The de- No study has shown that bacteremia spontaneously
velopment of reliable microbiologic marker opens in- occurs in cases of infected root canals associated with
teresting perspectives. The increasing knowledge about a chronic periradicular lesion. Bacteremia can occur in
major endodontic pathogens coupled with advances in cases of acute periradicular abscesses and during the
microbiologic diagnostic tests may accelerate the de- treatment of infected root canals.92,93,98 Although it has
velopment of reliable microbiologic markers. been demonstrated that the microbial species present in
An alternative type of end point marker might be the blood of patients undergoing endodontic therapy are
based on host response. Although there is a myriad of the same as those present in their root canals,98 such
information regarding the chemical mediators impli- findings only mean that endodontic therapy can cause
cated in the pathogenesis of periradicular lesions,88 the bacteremia but not that microorganisms from the root
greatest obstacle to developing such host-based bio- canal cause damage in remote sites of the body.
logic marker is the fact that the dynamics and the In the absence of indisputable evidence regarding the
mechanisms of repair of periradicular lesions are poorly effects of bacteremia, consensus suggests that antibiotic
understood. Changes in levels of some of these medi- prophylaxis should be given to patients at risk to de-
ators might predict the healing pattern of the lesion. velop infective endocarditis, immunosuppressed pa-
Thus, the major challenge is to develop a reliable tients, and patients with orthopedic prosthetic devic-
procedure to sample the root canal and periradicular es.99
lesion and to establish which mediators are important Apart from these rare examples, in which there is
for the healing of the pathologic process. unproven but potential risk for complications following
bacteremia, the focal infection is a highly unlikely
FOCAL INFECTION phenomenon.
Despite anecdotal reports of patients who were cured
of various illnesses after tooth extraction, the focal SYSTEMIC ANTIBIOTIC THERAPY
infection theory has remained controversial because of The advent of antibiotics resulted in a significant de-
the lack of clear evidence regarding the causal relation- cline in the incidence of life-threatening infection and
ship between oral infections and general health. In heralded a new era in the therapy of infectious diseases.
reaction to the report of Hunter and others,89-91 den- During the ensuing years, microbial evolutionary re-
tistry for many years discarded the hypothesis of focal sponses to the selective pressure exerted by antibiotics
infection. However, a renewed interest in the focal have resulted in microbial species resistant to virtually
infection theory has been generated in recent years.92,93 every known antibiotic.100 If a given member of a micro-
Recent reports from epidemiologic studies have again bial community possesses genes of resistance against a
shifted the paradigm in favor of accepting the possibil- certain antibiotic and the community is persistently ex-
ity that dental focal infections may occur.94,95 posed to the drug, the resistant microorganism is selected
Findings from epidemiologic studies can only detect to emerge and multiply. The occurrence of multidrug
relationship but are insufficient to establish causation.96 resistant strains of Staphylococcus aureus, Enterococcus
No well-controlled experimental study using a reliable faecalis, Pseudomonas aeruginosa, Streptococcus pneu-
and reproducible method has substantiated the focal moniae, Mycobacterium tuberculosis, and many other
infection theory. The establishment of a causal link is species capable of causing life-threatening infections has
one of the most important steps in determining whether been reported.100-103 In addition, antibiotic resistance
the microorganism associated with the remote disorder among anaerobic bacteria, including the species com-
is the same as the suspected oral microorganism, in- monly found in oral infections, is increasing, with signif-
cluding species, biotype, serotype, and genotype. In icant resistance to clindamycin, cephalosporins, and pen-
addition, the onset of the specific disease should follow icillins noted at community hospitals and major medical
the onset of the oral disease. In cases in which the centers.103
dental procedure is the suspect for causing bacteremia, The increasing development of multiresistant strains
the onset of the specific disease should be within the has resulted in the reemergence of diseases judged to be
incubation period.96 under control and in the persistence of infectious pro-
Bacteremia, which is usually transient, can occur cesses regardless of therapy with antibiotics that was
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Siqueira 291
Volume 94, Number 3

usually effective in treating the same diseases in the 16S rRNA to find the cause of Whipple’s disease. N Engl J Med
1992;327:293-301.
past. Therefore, patients infected with a multidrug re- 10. Salyers AA, Whitt DD. Bacterial pathogenesis: a molecular
sistant microorganism suffer increased morbidity and approach. Washington: ASM Press; 1994. p. 418.
mortality. 11. van Steenbergen TJM, Delemarre FGA, Namavar F, De Graaff
Overuse and misuse of antibiotics have been consid- J. Differences in virulence within the species Bacteroides gin-
givalis. Antonie van Leeuwenhoek 1987;53:233-44.
ered as the major causes responsible for the emergence 12. Griffen AL, Lyons SR, Becker MR, Moeschberger ML, Leys
of multidrug resistant strains. Improper use of antibiot- EJ. Porphyromonas gingivalis strain variability and periodon-
ics includes use in cases in which no infection is titis. J Clin Microbiol 1999;37:4028-33.
13. Mims C, Nash A, Stephen J. Mims’ pathogenesis of infectious
present, erroneous choice of the agent, dosage or dura- diseases. 5th ed. San Diego: Academic Press; 2001. p. 361-91.
tion of therapy, and excessive use in prophylaxis.99 14. Socransky SS. Criteria for the infectious agents in dental caries
Antibiotics are used in clinical practice far more often and periodontal disease. J Clin Periodontol 1979;6(extra issue):
16-9.
than is necessary. Although antibiotic therapy is actu- 15. Socransky SS, Haffajee AD. Microbiology of periodontal dis-
ally warranted in about 20% of the individuals who are ease. In: Lindhe J, Karring T, Lang NP (editors). Clinical
seen for clinical infectious disease, antibiotics are pre- periodontology and implant dentistry. 3rd ed. Copenhagen:
Munksgaard; 1997. p. 138-88.
scribed up to 80% of the time. To compound this 16. Dahlén G, Fabricius L, Heyden G, Holm SE, Möller AJR.
problem, in nearly 50% of cases the recommended Apical periodontitis induced by selected bacterial strains in root
agent, dose, or duration of therapy is incorrect.101 canals of immunized and nonimmunized monkeys. Scand J
Dent Res 1982;90:207-16.
The purpose of antibiotic therapy is to aid the host 17. Fabricius L, Dahlén G, Holm SE, Möller AJR. Influence of
defenses in controlling and eliminating microorganisms combinations of oral bacteria on periapical tissues of monkeys.
that temporarily have overwhelmed the host defense Scand J Dent Res 1982;90:200-6.
18. Sundqvist GK, Eckerbom MI, Larsson AP, Sjögren UF. Capac-
mechanisms.104 The most important decision in antibi- ity of anaerobic bacteria from necrotic dental pulps to induce
otic therapy is not so much which antibiotic should be purulent infections. Infect Immun 1979;25:685-93.
used but whether antibiotics should be used at all. 19. Baumgartner JC, Falkler WA Jr, Beckerman T. Experimentally
The vast majority of infections of endodontic origin induced infection by oral anaerobic microorganisms in a mouse
model. Oral Microbiol Immunol 1992;7:253-6.
are treated without the need for antibiotics. Because of 20. Siqueira JF Jr, Magalhães FAC, Lima KC, Uzeda M. Pathoge-
the absence of blood circulation within a necrotic and nicity of facultative and obligate anaerobic bacteria in monocul-
infected pulp, antibiotics cannot reach and eliminate ture and combined with either Prevotella intermedia or Pre-
votella nigrescens. Oral Microbiol Immunol 1998;11:368-72.
microorganisms present in the root canal system. Thus, 21. Baumgartner JC, Falkler WA Jr. Bacteria in the apical 5 mm of
the source of infection is unaffected by systemic anti- infected root canals. J Endod 1991;17:380-3.
biotic therapy. On the other hand, antibiotics can help 22. Happonen R-P. Periapical actinomycosis: a follow-up study of
16 surgically treated cases. Endod Dent Traumatol 1986;2:
to impede spreading of the infection and the develop- 205-9.
ment of secondary infections in compromised patients. 23. Gomes BPFA, Lilley JD, Drucker DB. Clinical significance of
Therefore, antibiotics can be a valuable adjunct for the dental root canal microflora. J Dent 1996;24:47-55.
24. Griffee MB, Patterson SS, Miller CH, Kafrawy AH, Newton
management of some few cases of endodontic infec- CW. The relationship of Bacteroides melaninogenicus to symp-
tion. toms associated with pulpal necrosis. Oral Surg Oral Med Oral
Pathol 1980;50:457-61.
25. Haapasalo M, Ranta H, Ranta K, Shah H. Black-pigmented
REFERENCES Bacteroides spp in human apical periodontitis. Infect Immun
1. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical 1986;53:149-53.
exposures of dental pulps in germ-free and conventional labo- 26. Le Goff A, Bunetel L, Mouton C, Bonnaure-Mallet M. Evalu-
ratory rats. Oral Surg Oral Med Oral Pathol 1965;18:340-8. ation of root canal bacteria and their antimicrobial susceptibility
2. Möller AJR. Microbial examination of root canals and periapi- in teeth with necrotic pulp. Oral Microbiol Immunol 1997;12:
cal tissues of human teeth. Odontologisk Tidskrift 1966; 318-22.
74(suppl):1-380. 27. Machado de Oliveira JC, Siqueira JF Jr, Alves GB, Hirata R Jr,
3. Sundqvist G. Bacteriological studies of necrotic dental pulps Andrade AFB. Detection of Porphyromonas endodontalis in
[dissertation]. Umea (Sweden): University of Umea; 1976. infected root canals by 16s rRNA gene-directed polymerase
4. Möller AJR, Fabricius L, Dahlén G, Öhman AE, Heyden G. chain reaction. J Endod 2000;26:729-32.
Influence on periapical tissues of indigenous oral bacteria and 28. Molander A, Reit C, Dahlén G, Kvist T. Microbiological status
necrotic pulp tissue in monkeys. Scand J Dent Res 1981;89: of root-filled teeth with apical periodontitis. Int Endod J 1998;
475-84. 31:1-7.
5. Nair PNR. Light and electron microscopic studies of root canal 29. Peciuliene V, Balciuniene I, Eriksen HM, Haapasalo M. Isola-
flora and periapical lesions. J Endod 1987;13:29-39. tion of Enterococcus faecalis in previously root-filled canals in
6. Fredricks DN, Relman DA. Sequence-based identification of a Lithuanian population. J Endod 2000;26:593-5.
microbial pathogens: a reconsideration of Koch’s postulates. 30. Rôças IN, Siqueira JF Jr, Santos KR, Coelho AM. “Red com-
Clin Microbiol Rev 1996;9:18-33. plex” (Bacteroides forsythus, Porphyromonas gingivalis, and
7. Relman DA. The search for unrecognized pathogens. Science Treponema denticola) in endodontic infections: a molecular
1999;284:308-10. approach. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
8. Relman DA. The identification of uncultured microbial patho- 2001;91:468-71.
gens. J Infect Dis 1993;168:1-8. 31. Siqueira JF Jr, Rôças IN, Souto R, Uzeda M, Colombo AP.
9. Relman DA, Schmidt TM, MacDermott RP, Falkow S. Using Checkerboard DNA-DNA hybridization analysis of endodontic
292 Siqueira ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
September 2002

infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Wannemuehler MJ (editors). Virulence mechanisms of bacte-
2000;89:744-8. rial pathogens. 3rd ed. Washington (DC): ASM Press; 2000.
32. Siqueira JF Jr, Rôças IN, Souto R, Uzeda M, Colombo AP. 57. Kolenbrander PE. Environmental sensing mechanisms and vir-
Microbiological evaluation of acute periradicular abscesses by ulence factors of bacterial pathogens. In: Collier L, Balows A,
DNA-DNA hybridization. Oral Surg Oral Med Oral Pathol Oral Sussman M (editors). Topley & Wilson’s microbiology and
Radiol Endod 2001;92:451-7. microbial infections (vol 2, Systematic bacteriology). 9th ed.
33. Siqueira JF Jr, Rôças IN, Oliveira JCM, Santos KRN. Detection London: Arnold; 1998. p. 307-26.
of putative oral pathogens in acute periradicular abscesses by 58. Siqueira JF Jr. Aetiology of the endodontic failure: why well-
16S rDNA directed PCR. J Endod 2001;27:164-7. treated teeth can fail. Int Endod J 2001;34:1-10.
34. Siqueira JF Jr, Rôças IN, Favieri A, Santos KRN. Detection of 59. Sirén EK, Haapasalo MPP, Ranta K, Salmi P, Kerosuo ENJ.
Treponema denticola in endodontic infections by 16S rRNA Microbiological findings and clinical treatment procedures in
gene directed polymerase chain reaction. Oral Microbiol Im- endodontic cases selected for microbiological investigation. Int
munol 2000;15:335-7. Endod J 1997;30:91-5.
35. Sjögren U, Happonen RP, Kahnberg KE, Sundqvist G. Survival 60. Nair PNR, Sjögren U, Krey G, Kahnberg K-E, Sundqvist G.
of Arachnia propionica in periapical tissue. Int Endod J 1988; Intraradicular bacteria and fungi in root-filled, asymptomatic
21:277-82. human teeth with therapy-resistant periapical lesions: a long-
36. Sundqvist G, Fidor D, Persson S, Sjögren U. Microbiologic term light and electron microscopic follow-up study. J Endod
analysis of teeth with failed endodontic treatment and the out- 1990;16:580-8.
come of conservative re-treatment. Oral Surg 1998;85:86-93. 61. Tronstad L, Barnett F, Riso K, Slots J. Extraradicular endodon-
37. Sundqvist G, Johansson E, Sjögren U. Prevalence of black- tic infections. Endod Dent Traumatol 1987;3:86-90.
pigmented Bacteroides species in root canal infections. J Endod 62. Tronstad L, Barnett F, Cervone F. Periapical bacterial plaque in
1989;15:13-9. teeth refractory to endodontic treatment. Endod Dent Traumatol
38. Sundqvist G. Associations between microbial species in dental 1990;6:73-7.
root canal infections. Oral Microbiol Immunol 1992;7:257-62. 63. Iwu C, Macfarlane TW, Mackenzie D, Stenhouse D. The mi-
39. Sundqvist G. Taxonomy, ecology, and pathogenicity of the root crobiology of periapical granulomas. Oral Surg Oral Med Oral
canal flora. Oral Surg Oral Med Oral Pathol 1994;78:522-30. Pathol 1990;69:502-5.
40. Waltimo TMT, Sirén EK, Torkko HLK, Olsen I, Haapasalo 64. Wayman BE, Murata SM, Almeida RJ, Fowler CB. A bacteri-
MPP. Fungi in therapy-resistant apical periodontitis. Int Endod ological and histological evaluation of 58 periapical lesions. J
J 1997;30:96-101. Endod 1992;18:152-5.
41. van Winkelhoff AJ, Carlee AW, de Graaff J. Bacteroides end- 65. Sunde PT, Tronstad L, Eribe ER, Lind PO, Olsen I. Assessment
odontalis and other black-pigmented Bacteroides species in of periradicular microbiota by DNA-DNA hybridization. Endod
odontogenic abscesses. Infect Immun 1985:49:494-8.
Dent Traumatol 2000;16:191-6.
42. Baumgartner JC, Falkler WA Jr, Bernie RS, Suzuki JB. Serum
66. Gatti JJ, Dobeck JM, Smith C, White RR, Socransky SS, Skobe
IgG reactive with oral anaerobic microorganisms associated
Z. Bacteria of asymptomatic periradicular endodontic lesions
with infections of endodontic origin. Oral Microbiol Immunol
identified by DNA-DNA hybridization. Endod Dent Traumatol
1992;7:106-10.
2000;16:197-204.
43. Kettering JD, Torabinejad M, Jones SL. Specificity of antibod-
67. Nair PNR, Schroeder HE. Periapical actinomycosis. J Endod
ies present in human periapical lesions. J Endod 1991;17:213-6.
1984;12:567-70.
44. Stashenko P. The role of immune cytokines in the pathogenesis
of periapical lesions. Endod Dent Traumatol 1990;6:89-96. 68. Siqueira JF Jr, Lopes HP. Bacteria on the apical root surfaces of
45. Horiba N, Maekawa Y, Abe Y, Ito M, Matsumoto T, Nakamura untreated teeth with periradicular lesions: a scanning electron
H. Correlations between endotoxin and clinical symptoms or microscopy study. Int Endod J 2001;34:216-20.
radiolucent areas in infected root canals. Oral Surg Oral Med 69. Henderson B, Poole S, Wilson M. Bacterial modulins: a novel
Oral Pathol 1991;71:492-5. class of virulence factors which cause host tissue pathology by
46. Hashioka K, Suzuki K, Yoshida T, Nakane A, Horiba N, inducing cytokine synthesis. Microbiol Rev 1996;60:316-41.
Nakamura H. Relationship between clinical symptoms and en- 70. Nair SP, Meghji S, Wilson M, Reddi K, White P, Henderson B.
zyme-producing bacteria isolated from infected root canals. J Bacterially induced bone destruction: mechanisms and miscon-
Endod 1994;20:75-7. ceptions. Infect Immun 1996;64:2371-80.
47. Maita E, Horiuchi H. Polyamine analysis of infected root canal 71. Heeg K, Sparwasser T, Lipford GB, Hacker H, Zimmermann S,
contents related to clinical symptoms. Endod Dent Traumatol Wagner H. Bacterial DNA as an evolutionary conserved ligand
1990;6:213-7. signalling danger of infection to immune cells. Eur J Clin
48. Fabricius L, Dahlén G, Ohman AE, Möller AJR. Predominant Microbiol Infect Dis 1998;17:464-9.
indigenous oral bacteria isolated from infected root canals after 72. Bassler BL. How bacteria talk to each other: regulation of gene
varied times of closure. Scand J Dent Res 1982;90:134-44. expression by quorum sensing. Curr Opin Microbiol 1999;2:
49. Tani-Ishii N, Wang C-T, Tanner A, Stashenko P. Changes in 582-7.
root canal microbiota during the development of rat periapical 73. Lazazzera BA. Quorum sensing and starvation: signals for entry
lesions. Oral Microbiol Immunol 1994;9:129-35. into stationary phase. Curr Opin Microbiol 2000;3:177-82.
50. Miller WD. An introduction to the study of the bacterio-pathol- 74. Withers H, Swift S, Williams P. Quorum sensing as an integral
ogy of the dental pulp. Dent Cosmos 1894;36:505-28. component of gene regulatory networks in Gram-negative bac-
51. Siqueira JF Jr. Tratamento das infecções endodônticas. Rio de teria. Curr Opin Microbiol 2001;4:186-93.
Janeiro: MEDSI; 1997. 75. Gray KM. Intercellular communication and group behavior in
52. Siqueira JF, Rôças IN, Oliveira JCM, Santos KRN. Molecular bacteria. Trends Microbiol 1997;5:184-8.
detection of black-pigmented bacteria in infections of endodon- 76. Ramos JL, Gallegos MT, Marqués S, Ramos-González MI,
tic origin. J Endod 2001;27:563-6. Espinosa-Urgel M, Segura A. Responses of Gram-negative
53. Baumgartner JC, Watkins BJ, Bae KS, Xia T. Association of bacteria to certain environmental stressors. Curr Opin Micro-
black-pigmented bacteria with endodontic infections. J Endod biol 2001;4:166-71.
1999;25:413-5. 77. Frias J, Olle E, Alsina M. Periodontal pathogens produce quo-
54. Finlay BB, Falkow S. Common themes in microbial pathoge- rum sensing signal molecules. Infect Immun 2001;69:3431-4.
nicity. Microbiol Rev 1989;53:210-30. 78. Matin A. Physiology, molecular biology and applications of the
55. Finlay BB, Falkow S. Common themes in microbial pathoge- bacterial starvation response. J Appl Bacteriol 1992;73(sympo-
nicity revisited. Microbiol Mol Biol Rev 1997;61:136-69. sium suppl):49S-57S.
56. Brogden KA, Roth JÁ, Stanton TB, Bolin CA, Minion FC, 79. Amann RI, Ludwig W, Schleifer KH. Phylogenetic identifica-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Siqueira 293
Volume 94, Number 3

tion and in situ detection of individual microbial cells without 93. Murray CA, Saunders WP. Root canal treatment and general
cultivation. Microbiol Rev 1995;59:143-69. health: a review of the literature. Int Endod J 2000;33:1-18.
80. Paster BJ, Boches SK, Galvin JL, Ericson RE, Lau CN, Leva- 94. Mattila KJ, Nieminen MS, Valtonen VV, Rasi VP, Kesäniemi
nos VA, et al. Bacterial diversity in human subgingival plaque. YA, Syrjälä SL, et al. Association between dental health and
J Bacteriol 2001;183:3770-83. acute myocardial infarction. Br Med J 1989;298:779-81.
81. Hashimura T, Sato M, Hoshino E. Detection of Slackia exigua, 95. Syrjänen J, Peltola J, Valtonen V, Livanainen M, Kaste M,
Mogibacterium timidum and Eubacterium saphenum from pul- Huttunen JK. Dental infections in association with certain in-
pal and periradicular samples using the Polymerase Chain Re- farction in young and middle-aged men. J Intern Med 1989;
action (PCR) method. Int Endod J 2001;34:463-70. 225:179-84.
82. Conrads G, Gharbia SE, Gulabivala K, Lampert F, Shah HN. 96. Slots J. Casual or causal relationship between periodontal in-
The use of a 16S rDNA PCR for the detection of endodonto- fection and non-oral disease? J Dent Res 1998;77:1764-5.
pathogenic bacteria. J Endod 1997;23:433-8. 97. Guntheroth WG. How important are dental procedures as a
83. Gonçalves RB, Mouton C. Molecular detection of Bacteroides cause of infective endocarditis? Am J Cardiol 1984;54:797-801.
forsythus in infected root canals. J Endod 1999;25:336-40. 98. Debelian GJ, Eribe ER, Olsen I, Tronstad L. Ribotyping of
84. Xia T, Baumgartner JC, David LL. Isolation and identification bacteria from root canal and blood of patients receiving end-
of Prevotella tannerae from endodontic infections. Oral Micro- odontic therapy. Anaerobe 1997;3:237-43.
biol Immunol 2000;15:273-5. 99. Pallasch TJ. Pharmacology of anxiety, pain and infection. In:
85. Jung I-Y, Choi B-K, Kum K-Y, Yoo Y-J, Yoon T-C, Lee S-J, Ingle JI, Bakland LK (editors). Endodontics. 4th ed. Baltimore:
Williams & Wilkins; 1994. p. 641-79.
et al. Identification of oral spirochetes at the species level and
100. Hayward CMM, Griffin GE. Antibiotic resistance: the current
their association with other bacteria in endodontic infections.
position and the molecular mechanisms involved. Br J Hosp
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:
Med 1994:52:473-8.
329-34.
101. Madigan MT, Martinko JM, Parker J. Brock biology of micro-
86. Rolph HJ, Lennon A, Riggio MP, Saunders WP, MacKenzie D, organisms. 9th ed. Upper Saddle River (NJ): Prentice-Hall;
Coldero L, et al. Molecular identification of microorganisms 2000.
from endodontic infections. J Clin Microbiol 2001;39:3282-9. 102. Whitney CG, Farley MM, Hadler J, et al. Increasing prevalence
87. Spangberg LSW. Endodontics today: a turn-of-the-century re- of multidrug-resistant Streptococcus pneumoniae in the United
flection [editorial]. Oral Surg Oral Med Oral Pathol Oral Radiol States. N Engl J Med 2000;343:1917-24.
Endod 2000;89:659. 103. Hecht DW, Vedantam G, Osmolski JR. Antibiotic resistance
88. Torabinejad M. Mediators of acute and chronic perirradicular among anaerobes: what does it mean? Anaerobe 1999;5:421-9.
lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104. Pallasch TJ. Pharmacokinetic principles of antimicrobial ther-
1994;78:511-21. apy. Periodontology 2000 1996;10:5-11.
89. Hunter W. Oral sepsis as a cause of disease. Brit Med J
1900;2:215-6. Reprint requests:
90. Billings F. Chronic focal infections and their etiologic relations
to arthritis and nephritis. Arch Int Med 1912;9:484-98. José F. Siqueira, Jr, DDS, MSc, PhD
91 Rosenow EC. Mouth infection as a source of systemic disease. R. Herotides de Oliveira 61/601
JAMA 1914;63:2026-7. Icaraı́, Niterói, RJ
92. Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic diseases Brazil 24230-230
caused by oral infection. Clin Microbiol Rev 2000;13:547-58. [email protected]

To receive the tables of contents by e-mail, sign up through our Web site at:
http://www.mosby.com/tripleo
Choose e-mail notification. Simply type your e-mail address in the box and click the
Subscribe button.
Alternatively, you may send an e-mail message to [email protected]. Leave the sub-
ject line blank and type the following as the body of your message:
subscribetripleo_toc
You will receive an e-mail to confirm that you have been added to the mailing list. Note that
the table of contents e-mails will be sent out when a new issue is posted to the Web site.