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Periodontology 2000, Vol.

5, 1994, 52-65
Printed in Denmark All rights reserved

Copvrinht 0 Munksnaard 1994

PERIODONTOLOGY 2000
ISSN 0906-6713

The structure of dental plaque


MAXA. LISTGARTEN
Dental plaque has been defined as the nonmineralized microbial accumulation that adheres tenaciously to tooth surface, restorations, and prosthetic appliances, shows structural organization with
predominance of filamentous forms, is composed of
an organic matrix derived from salivary glycoproteins and extracellular microbial products, and
cannot be removed by rinsing or water spray (102).
The structure of dental plaque refers to the manner
in which the elements of dental plaque, predominantly bacteria, are organized and interrelated.
Although this definition may suggest a vision of a
rather static assembly of microorganisms contentedly sticking to a solid surface, nothing could be
further from the truth. Indeed, the origin of dental
plaque, its development and adaptation to changing
environmental conditions are all governed by a dynamic, ever-changing equilibrium between the oral
microbiota and a multitude of factors that differentially promote or inhibit the survival of its microbial
constituents. For the sake of this discussion, the
definition of dental plaque will be expanded to also
include microorganisms that may be only loosely attached to assorted surfaces in the oral cavity, including firmly adherent bacteria.

Development and maturation of


the microbiota of dental plaque
The earliest microbiota to colonize the mouth of the
newborn infant is derived from the mothers genital
tract, oral cavity and skin. Since the newborn infant
has no teeth, the earliest microbial colonizers will be
those that are able to adhere to the available surfaces: those lined by epithelium (83). Streptococcus
salivarius, which is such an organism, becomes established within one day of birth (23). At the time of
delivery, the childs mouth also becomes infected
with Lactobacillus jensenii and Lactobacillus acidophilus (22).However, these and some gram-negative
anaerobic species (60) remain at low levels and do
not persist, presumably because of the absence of

52

teeth, which normally favor their retention. Lactobacillus does not reappear in the mouth until after
age 2, usually as Lactobacillus casei, the dominant
oral species.
Streptococcus sanguis, an organism that preferentially colonizes tooth surfaces, can be recovered
shortly after the teeth erupt (23). Streptococcus mutans, which favors the same ecological niche, was absent from the mouths of 91 predentate infants but
was detected in 9 of 40 infants with only erupted
primary incisors (9) and half of a group of 2-yearolds (57). It has been shown that, if mothers are
treated so as to reduce their levels of S. mutans, the
rate of transmission of S. mutans to their infants can
be reduced by as much as one-third (57).
Actinomyces naeslundii, a predominant species of
dental plaque, is recovered from 40% of young
children. Actinomyces uiscosus which is absent in infants, gradually increases in prevalence as the child
grows older, with half the children colonized by age
7 (36). Veillonella species follow a similar pattern of
increasing prevalence with increasing age (86).
Although most infants harbor a predominantly
gram-positive, facultative microbiota, anaerobes can
also be recovered (59), particularly after tooth
emergence. As many as 61% of children aged 5-7
years harbor black-pigmenting gram-negative anaerobes (7, 30, 41, 84), as well as spirochetes (30, 84,
90). The proportion of these organisms and other
strict anaerobes increases in adolescence and adulthood (106, 147) but may show a great deal of siteto-site variability (14),with local factors such as pH,
eH and assorted bacterial interactions playing an
important role (89). Some variability is also due to
such factors as the state of health of the dentition
(Table 1) and periodontal tissues (5, 6, 17, 31, 33),
the medical status of the patients (8, 18, 19, 43, 87)
and their racial origin (21,120).
With the loss of teeth in older adults, some ecological niches such as tooth surfaces and gingival
sulci that favor the retention of certain species are
lost. As these specialized environments disappear
there is a marked reduction, if not a complete elimination, of such species as Actinobacillus actino-

The structure of dental plaque

Table 1. Microbiology of the periodontal region: representative species in periodontal health and disease
Health
Juvenile periodontitis
Streptococcus sanguis
Actinobacillus actinomycetemcomitans
Streptococcus mitis
Other bacterial species (?)
Veillonella parvula
Actinomyces naeslundii
Rapidly progressive periodontitis
Actinomyces viscosus
Actinobacillus actinomycetemcomitans
Rothia dentocariosa
Porphyromonas gingivalis
Bacteroidesforsythus
Gingivitis
Campylobacter rectus
Actinomyces species
Eikenella corrodens
Streptococcus species
Veillonella species
Refractory periodontitis
Fasobacterium species
Actinobacillus actinomycetemcomitans
Treponema species
Porphyromonas gingivalis
Prevotella intermedia
Prevotella intermedia
Bacteroides forsythus
Adult periodontitis
Campylobacter rectus
Treponema species
Peptostreptococcus micros
Enteric rods
Prevo tella intermedia
Porphyromonas gingivalis
Candida species
Bacteroidesforsythus
Peptostreptococcus micros
Campylobacter rectus
Actinobaciltus actinomycetemcomitans
Eikenella corrodens
Fusobacterium species
Selenomonas species
Eubacterium species

mycetemcomitans, Lactobacilli, S. mutans, S. sanguis


and spirochetes. By contrast, species that do not depend on the presence of teeth, for example Candidu,
continue to thrive (2, 58, 133).

Methods to study the


morphological features of dental
plaque
Much of the above information was derived from
cultural studies of supragingival dental plaque in
subjects of various ages. At the same time, studies
were ongoing to clarify the morphological characteristics of dental plaque. Some of these studies examined dental plaque on natural teeth; others collected
dental plaque on tooth sections or artificial substrates placed in the oral cavity for defined periods
of time. Plaque morphology has been examined by
light and transmission electron microscopy of sections through the plaque layer (38, 39, 47, 51, 70, 82,
101, 122, 124, 125, 141). Other studies analyzed
plaque by light microscopy of whole or dispersed
plaque (50, 95, 112, 113, 116), or scanning electron
microscopy of plaque deposits (24, 42, 53, 98, 99,
101, 115) or plaque deposit replicas (61,119).

The results of these and other investigations demonstrated that dental plaque is composed of a large
variety of bacterial morphotypes with some significant heterogeneity in the appearance of the microbial deposits. Because of the lack of standardization, it has been difficult to relate the findings from
one study to another. Furthermore, most of the
studies were not designed to investigate the dynamics of plaque formation at the cellular level but
rather to provide a cross-sectional view of plaque
structure in one or more subjects at a particular
point in time. However, in at least one study (791,
data were obtained that provided some new insight
into the process of dental plaque formation and
maturation. A related study also demonstrated that
detectable morphological differences could be observed among dental plaques from mouths with differing states of periodontal health (70). These studies
are reviewed in greater detail later.

Microbiota of dental implants


With the increasing use of dental implants to replace
missing teeth, investigators also have been exploring
the oral microbiota associated with dental implants.

53

Early studies focused on differences in the composition of the microbiota associated with stable and
failing implants. The reports generally indicated that
healthy implants have a microbiota similar to that of
healthy teeth, while failing implants have a microbiota similar to that found around teeth with periodontitis (1, 91, 93, 110, 111, 117). It is likely, however, that around failing implants the composition
of the microbiota may be related to the nature of the
implant failure. Thus if a microbiota is found resembling that of adult periodontitis, the failure is probably infectious in nature (infectious peri-implantitis), since in failures due to traumatic injury
the microbiota is similar to that around stable implants or periodontally healthy teeth (114). These
dramatic differences between failures due to trauma
and failures due to infection presumably apply only
to cases that fall clearly either into one or the other
category. The possibility exists that an implant failure initially due to trauma may become secondarily
infected, with an accompanying shift in the composition of the microbiota. Resolving the infection may
not necessarily solve the primary clinical problem,
which is occlusal in nature.
It is noteworthy that spirochetes and Porphyrornonas gingiualis do not colonize healthy implants in
an edentulous mouth as readily as they do implants
in partially edentulous patients (92, 97, 105, 107).
The frequently reported absence of spirochetes
around healthy implants in edentulous mouths
coupled with their presence in low numbers around
healthy fixtures in dentulous patients suggests that
diseased teeth may serve as a source of infection for
dental implants (107). Should this be the case, controlling periodontal infections prior to implant
placement ought to improve the long-term survival
rate of dental implants.
Since a variety of materials are used in the manufacturing of dental implants, some studies have
examined the influence of materials on plaque formation in situ (46, 54, 96, 108, 109, 146). It appears
that materials can affect the rate of early plaque formation, that is, within the first few hours of exposing
the fresh surface to the intraoral environment. After
4 hours in the mouth, some differences were noted
in the rate of plaque formation on disks of assorted
materials, including titanium and hydroxyapatite,
that were glued to the gingiva. Quirynen et al. (108)
and Weerkamp et al. (146) observed a direct correlation between plaque accumulation on a variety of
substrates and increasing surface free energy. However, surface roughness emerged as a more important factor than surface free energy in promoting

54

early plaque accumulation. After 48 hours, there was

no longer any detectable difference in the plaque


collected on the different materials by Nakazato et
al. (96) These observations were supported by Quirynen et al. (1091, who detected significant differences between rough and smooth surfaces for as
long as 6 days. An earlier suggestion that titanium
possesses some antimicrobial properties has been
refuted (54).

Use of artificial substrates to study


dental plaque formation
The effect of certain materials on plaque formation
has also been of interest to other investigators
attempting to identify suitable experimental substrates for studying plaque development in uiuo. Berthold et al. (10) noted a similar plaque morphology
on enamel and polished epoxy resin after 2-5 days of
plaque formation. However, the morphology differed
from that of plaque collected on sand-blasted Mylar
strips and sand-blasted epoxy resin. Plaque thickness tended to be greater on the roughened surfaces,
a finding that is compatible with Nakazatos (96) observation that roughness is more important than
surface free energy in promoting early plaque formation on assorted implant materials.
Lie (62, 65) produced veneers composed of a mixture of epoxy resin and hydroxyapatite that could be
glued to the buccal surfaces of posterior teeth in human volunteers for various periods of time. His
short-term findings indicated that organic pellicles
tended to adsorb to the hydroxyapatite particles
earlier and form more well-defined adherent layers
than on the epoxy resin in which the hydroxyapatite
particles were embedded (66, 67). Plaque formation
also tended to be faster on hydroxyapatite than epoxy resin. However, the differences in rates of plaque
formation and maturation had disappeared by 48
hours (65). Colonization began in pits and fissures
from which the bacteria spread as monolayers over
the adjacent surfaces. Scanning electron microscopy
revealed a predominance in early plaque of coccoid
cells, with some rods and a few filaments.

Structural features of developing


dental plaque
Listgarten et al. (79) recruited human volunteers in
need of full-crown restorations to participate in a

The structure of dental plaque

study of dental plaque development. A series of


identical epoxy resin crowns were fabricated for each
subject. These crowns were worn for different time
periods, according to a predetermined schedule, to
provide plaque samples of different maturities from
the same anatomic site in each volunteer. The
periods of plaque formation varied from 1 day to 2
months. The experimental design allowed the investigators to obtain sections through undisturbed dental plaque that could be studied both at the light and
transmission electron microscopic level. The resulting data provided for the first time information on
the chronological changes that take place in supraas well as subgingival dental plaque from a specific
location in the mouth of several human subjects.
The following is a summary of the main structural
features that characterize developing human dental
plaque. It is based in part on results from the epoxy
resin crown model as well as other reports in the
literature that have investigated various stages in the
plaque formation process (13, 15, 16, 137, 138). Since
the morphology of developing dental plaque on
tooth surfaces and smooth epoxy resin surface appears to be similar, the description that follows, although referring to the tooth surface, is based on
data from both natural teeth as well as artificial substrates. Where differences are known to exist, these
will be pointed out.
Formation of supragingival dental plaque

Within minutes after a tooth surface is freshly


cleaned, an acquired pellicle, composed primarily of
salivary proteins, is adsorbed to the exposed hydroxyapatite crystallites (4, 20, 69, 100, 128).
Morphologically similar coatings are produced on
various other substrates, albeit at different rates (1 1,
63). Their chemical composition may be affected by
the physical and chemical nature of the surfaces and
the distribution of surface charges (64, 134). Because
of the speed with which acquired pellicles are
formed, it is unlikely that bacterial colonization will
begin on any surface without prior formation of an
organic coating (Fig. 1).
The first bacteria to colonize the surface are mostly gram-positive, facultative cocci, mainly of the
Streptococcus species, and coccobacilli, mainly Actinomyces. Veillonella, a genus of gram-negative anaerobic cocci, is also an early colonizer. Initial colonization is characterized by a transient, reversible
attachment to the tooth. In time, the attachment becomes stronger and less readily ruptured. The
attachment is mediated through sticky proteo-

glycans covering the cell wall, as well as proteins in


fimbria and pili. These proteinaceous components
responsible for adhesion have been described as adhesins. They react with receptors on various oral surfaces. For a comprehensive review of these interactions, see Gibbons (44) and Gibbons et al. (45).
The earliest foci of bacterial accumulation are localized to surface pits and fissures but can also be
found on isolated protected portions of the smooth
surfaces. In time, the bacteria spread over larger sections of the smooth surfaces, with thicker accumulations at protected sites. Thus, plaque development
on smooth surfaces is favored on interdental surfaces and on portions of the tooth adjacent to the
gingival margin, where the developing plaque is protected from the frictional effect of adjacent soft
tissues such as the tongue and cheek.
Contrary to earlier prevailing views that plaque
grows by apposition of new bacteria at the plaque
surface, it is now clear that plaque grows in thickness
primarily through cell division of adherent bacteria.
This is readily demonstrated by analyzing sections of
freshly formed supragingival dental plaque on interdental surfaces or surfaces adjacent to the gingival
margin. During the first day, the surface is gradually
covered by colonies of dividing bacteria that initially
spread laterally along the tooth surface. Once the
available surface is covered, the proliferating bacteria begin to grow away from the tooth, in the form
of columnar microbial colonies that are closely
packed and compete for space and nutrients with
neighboring colonies (79). Around day 3, filamentous bacteria can be found on the surface of the predominantly coccoid plaque. Several species of coccoid bacteria are able to aggregate with some of the
filamentous bacteria to produce corncob formations that are detectable on the plaque surface (52,
79).

Competitive growth among the predominantly


coccoid microbial colonies continues for approximately 1 week (Fig. 2, 3). At that time, filamentous
bacteria begin to penetrate the coccoid plaque from
the surface, gradually replacing the coccoid microbiota with a predominantly filamentous microbiota.
The process may continue for approximately 2 more
weeks. By then the columnar microbial colonies
have disappeared and been replaced with a dense
mat of filamentous bacteria, orientated more or less
perpendicularly to the colonized surface. Corncob
formations may persist on the plaque surface (Fig.
4). This new structural organization remains relatively unchanged over time and can be identified in
supragingival plaque samples known to be 3 weeks

55

Fig. 1. One-day-old supragingival plaque on epoxy resin crown. The bacterial deposit (B) is attached to an electron-dense pellicle (P) which lines
the surface of the epoxy crown (E). X24,OOO; bar=l pm.
Fig. 2. One-week-old supragingival plaque on epoxy resin crown. The bulk
of this deposit consists of columnar colonies of coccoid bacteria (C) growing from the epon surface (E) outward. Some filamentous bacteria (F) have
colonized the plaque surface. x 1200.
Fig. 3. One-week-old supragingival plaque on epoxy crown. Three different
coccoid bacterial morphotypes (labelledA through C) have formed columnar microcolonies that compete for space as they grow away from the
crown surface (toward top of figure). X5400; bar=l pm.

to 2 months old as well as in supragingival plaque of


unknown age obtained from extracted teeth (38, 39,
51, 70, 79, 122). It can be considered as the typical,
relatively stable structure of mature, supragingival
dental plaque.

56

Calculus

Mineralization of supragingival as well as subgingiVal plaque gives rise to calculus. Mineralization generally proceeds in an incremental pattern from the

The structure of dental ulaaue

Fig. 4. Mature supragingival plaque on enamel surface (E). The bulk of the
deposit consists of filamentous bacteria (F). Corncob formations ( C ) are visible on the surface. x 1000.
Fig. 5. Mature subgingival plaque in periodontitis pocket. Test-tube brush
formations (T) cut through their long axis are surrounded by a predominantly
motile, gram-negative microbiota (M), rich in spirochetes. X 1700.
Fig. 6. Wo-month-old subgingival plaque adjacent to epoxy resin crown. The
microbiota is composed of predominantly gram-negative, anaerobic bacteria,
including thin, gram-negative filaments (F) and spirochetes (S). X 7800; bar=
1 pm.

inner zones of the dental plaque outward. This pattern of mineralization may give rise to Liesegang
rings, concentric rings reflecting successive phases
of mineralization, which are particularly noticeable
in old calculus deposits. For a comprehensive review
of calculus formation, see Schroeder (121). As new
layers of plaque become mineralized from the
deeper layers outward, the layering pattern throughout the deposit becomes emphasized, giving the erroneous impression that the entire deposit grew by
apposition of bacteria on the surface of the underlying calculus. Although calculus may grow in an incremental fashion through the progressive mineral-

ization of the overlying plaque, this growth pattern


differs markedly from that of dental plaque. As described earlier, increased thickness of plaque deposits, particularly in the early stages, primarily depends on bacterial proliferation and competitive
growth of microbial colonies within the plaque mass.

Formation of subgingival dental plaque


The undisturbed growth of supragingival plaque
gradually results in soft tissue alterations in the adjacent gingiva. Beginning within a few days of undisturbed plaque formation, the gingival margin begins

57

to show typical inflammatory changes, including


redness and swelling. The latter changes result in the
creation of a deepened gingival sulcus (pseudopocket), which provides a relatively anaerobic environment for the development of an anaerobic
microbiota. Anaerobic bacteria that colonize this
subgingival region include motile rods and spirochetes. They are able to increase their mass by contributing to the deepening of the sulcus, thereby increasing the volume of their ecological niche.
Because many of the subgingival microorganisms
are motile, the structural organization of this microbial population is quite different from that seen
supragingivally.
A relatively thin layer of adherent bacteria covers
the tooth surface. Rods and filaments tend to be arranged in a palisading pattern, with the long axis of
the cells perpendicular to the tooth surface. Unique
bacterial aggregates, resembling test-tube brushes,
can be found attached to the adhering plaque and
extending into the space between the bacterial layer
and the adjacent soft tissue wall (Fig. 5). The
bristles of these test-tube brush formations are
gram-negative filamentous bacteria, some of which
may be flagellated. The axial portion of the test-tube
brush consists of a single or several long filaments
held together by an amorphous extracellular matrix.
The bulk of the subgingival microbiota consists of a
complex mixture of predominantly anaerobic bacteria that surround and cover the test-tube brush
formations. The lack of well-defined microbial colonies in this environment may be due to the high degree of motility of the resident microbiota. The peripheral region of the subgingival microbiota is
composed of a high concentration of spirochetes
(Fig. 6, 7) that are in direct contact with the gingival
tissue wall as well as the apical lining of the sulcus or
pocket (140). Sometime a layer of leukocytes, mostly
neutrophils that have migrated out of the junctional
epithelium, separates the bacterial mass from the
sulcular or pocket epithelium.
The bottom of the sulcus or pocket is formed by
the coronal, desquamative surface of the junctional
epithelium, which is attached to the tooth surface
on one side and to the gingival connective tissue on
the other (126). This portion of the junctional epithelium is subject to bacterial as well as mechanical
injuries, which may result in enlarged intercellular
spaces and vertical tears in the epithelium. These
alterations in the integrity of the junctional epithelium allow a gradual apical colonization of the tooth
surface by coccoid cells and rods (123, 143, 144). Irregularities in the root surface, such as those caused

58

Fig. 7. Wo-month-old subgingival plaque adjacent to epoxy resin crown. The majority of the bacteria in this field
consist of spirochetes (S) with their distinctive ultrastructure. X52,OOO; bar=0.5 km.

by localized root resorption (127), may shelter


plaque microorganisms and contribute to their retention at such sites. The tendency for bacteria to
colonize tooth surfaces freshly exposed because of
disruptions in the junctional epithelium leads to a
gradual deepening of the sulcus or pocket.
Thus, a distinctive subgingival microbiota, predominantly composed of gram-negative, anaerobic
bacteria, including a number of motile species, becomes established in the gingival sulcus between
3-12 weeks after the beginning of supragingival
plaque formation. The establishment of this subgingival microbiota is dependent on a series of interrelated events: the successive colonization of the
tooth surface by different bacterial populations.
Each of these microbial populations appears to facilitate the colonization of this region by the next
wave of bacterial settlers, with the ultimate establishment in the subgingival region of a predominantly anaerobic, gram-negative microbiota. Most
bacterial species currently suspected of being periodontal pathogens are anaerobic, gram-negative
species whose main ecological niche is the subgingiVal region. In this protected environment they are in
an excellent position to participate in the destruction of the periodontal tissues, with the resulting
maintenance and expansion of their subgingival
habitat.

The structure of dental plaque

Fissure plaque
The microbial colonization of occlusal fissures is of
interest because of the relationship of the fissure
microbiota to the pathogenesis of dental caries. In
order to obtain a dynamic picture of the colonization
process in humans, Loe et al. (82) developed an artificial fissure made of Mylar foil, which they embedded in the occlusal surface of human mandibular
molars for periods of up to 2 months (55, 139, 142).
In the first week, the fissure first contained mostly
food debris, later replaced by gram-positive cocci,
mostly streptococci, short rods and yeast cells. Later,
lactobacilli appeared and increased in number with
time (136). Some filaments appeared after 3 weeks.
Some foci of mineralization were observed at about
the same time. After 2 months, the contents consisted mostly of gram-positive cocci and short rods,
many of which had undergone lysis, and some plant
wall material. No fusiform or spirillar forms were observed at any time (55, 139, 142).This type of plaque
did not exhibit the dynamic changes observed on
smooth tooth surfaces (139).

Relationship of plaque structure


to clinical status
The qualitative differences in the microbial populations observed over time in developing dental
plaque on epoxy resin crowns have an interesting
parallel in the natural dentition. Natural teeth were
extracted from patients with a diagnosis of health,
gingivitis or periodontitis (70). As the severity of the
periodontal condition increased, the composition of
the associated microbiota tended to replicate that
observed during plaque development on the resin
crowns.
The dental plaque associated with the periodontally healthy tooth was predominantly that of
early, supragingival plaque. It was characterized by a
predominantly coccoid microbiota, including many
gram-positive species. Cultural studies of such
plaques indicate that this microbiota is composed
predominantly of facultative bacteria. The gingivitisassociated microbiota was characterized by a
marked increase in the microbial mass as well as a
relative increase in the proportion of gram-negative
bacteria, motile rods and filaments. In adult periodontitis, an abundant, complex microbiota was observed in the periodontal pockets. This bacterial
population was predominantly gram-negative, in-

cluded test-tube brush formations similar to those


noted in the late maturation stages of developing
dental plaque on epoxy resin crowns and a large proportion of spirochetes preferentially distributed on
the periphery, or tissue side, of the microbial mass.
Cultural studies of such plaques indicate that this
microbiota is predominantly anaerobic.
In juvenile periodontitis, the dental plaque appeared less voluminous and less complex than in
adult periodontitis. Its morphological features did
not have a counterpart in the stages observed during
plaque development on epoxy resin crowns. Frequently, the exposed root surface within the pockets
was covered with a lobulated dental cuticle of varying thickness. Although in our study (70) this lobulated cuticle was typically observed in deep pockets
of patients with juvenile periodontitis, Friedman et
al. (40) also reported similar cuticles in adult periodontitis. Closely related to the cuticle were large,
gram-negative coccoid cells, later identified by Berthold et al. (12) as A. uctinomycetemcomituns, and
some palisading thin, gram-negative fusiform bacteria resembling Cupnocytophugu species.
The morphological differences in the composition
of the supra- and subgingival microbiotas in
humans, originally documented in sections of epoxy
resin crowns (119) as well as dental plaque sections
of extracted teeth with different periodontal conditions (70), could also be confirmed with technically simpler methods, such as dark-field and phasecontrast microscopy. By using dark-field microscopy
for differential counting of bacterial morphotypes in
bacterial scraping from the subgingival region,
Listgarten & Hellden (75) were able to show statistically significant differences in mean percentages of
various morphotypes between healthy and diseased
sites. Healthy sites had a predominantly coccoid
microbiota, with few if any spirochetes and motile
rods as compared with diseased sites in patients
with adult periodontitis. Furthermore, after mechanical debridement of periodontal pockets, Mousquks
et al. (94) demonstrated that bacterial recolonization
to pretreatment levels averaged 6 weeks, a time interval compatible with the chronological development of dental plaque in the epoxy resin crown
model (119).
Their findings support the concept that plaque
maturation in a diseased site is a process requiring
the orderly succession of bacterial populations until
one is left that is ultimately dominated by the anaerobic, gram-negative microbiota ordinarily found in
adult periodontitis pockets. Routine professional
cleanings coupled with daily oral hygiene prevent

59

Listgarten

such a microbiota from developing, by regularly removing recently formed dental plaque, thereby interfering with its maturation and ability to provide a
hospitable environment for a number of periodontal pathogens.
Our improved understanding of the dynamic nature of plaque formation has helped clarify the biological basis underlying the effectiveness of plaque
control on the clinical status of the periodontal
structures. Even though mechanical and some forms
of chemical plaque control are nonspecific methods
of reducing plaque mass, they also affect the qualitative nature of dental plaque. This is accomplished
through regular interference with the normal plaque
maturation process, which leads to the establishment of an anaerobic environment favorable to the
proliferation of most periodontal pathogens. Of
course, there are exceptions to this general observation. One example is that of A. actinomycetemcomitans infections, which may persist despite repeated mechanical debridement. This may be due,
in part, to the ability of A. actinomyceterncornitans, a
facultative bacterium, to colonize the dentition without the prior establishment of an anaerobic environment. It has also been suggested that the persistence
of A. actinomycetemcomitans may be due to its ability to invade and persist within periodontal tissues
(25, 27). Similarly, other periodontal pathogens may
be able to survive mechanical debridement and lead
to the production of periodontal diseases that have
been described as refractory to standard treatment.
Some reports indicate that, in relatively shortterm studies, supragingival plaque control has no
detectable influence on established subgingival
plaque in deep pockets, that is, with probing depths
of 7 mm or greater (56, 75). However, studies that
included shallower pockets or extended for one or
more years suggest that supragingival plaque control
not only results in beneficial clinical improvement
but also affects the composition of subgingival
plaque (29, 88, 131). Yet, even in long-term studies,
pockets with probing depths of 7 mm or greater were
not significantly affected by supragingival plaque
control alone (29). The apparent discrepancy between these results may be due to the cumulative
influence of a relatively minor effect of supragingival
plaque control on the subgingival microbiota. Waerhaug (145) demonstrated that toothbrushing was
able to disrupt subgingival plaque up to 0.9 mm
from the gingival margin. This effect may not be sufficient to cause immediate changes in the composition of the subgingival plaque of deep pockets. In
time, however, the cumulative effect of brushing and

60

periodontal prophylaxis may lead to a gradual


change in subgingival plaque composition of
pockets shallower than 7 mm. This qualitative shift
may be mediated not only through a direct effect of
mechanical debridement but also indirectly through
an altered immune response (34, 35), and environmental changes, such as reduced gingival inflammation and decreased pocket depth, that follow improved oral hygiene.

Clinical relevance of plaque


structure and composition
There is increasing evidence that the amount and
the composition of dental plaque are directly related
to the health status of the periodontal tissues (68).It
is also obvious that evaluation of plaque structure
and composition by means of histological sections is
not practical in a clinical setting. Therefore, indirect
means of obtaining this information are needed if
the information is to be applied to the management
of patients with periodontal problems.
The studies of dental plaque by light and electron
microscopy referenced earlier were crucial in demonstrating that plaque structure is intimately related
to microbial composition. Specific bacterial species
tend to occupy and thrive under specific environmental conditions and become organized into communities that give dental plaque its unique structural characteristics. Microscopic analysis of
dispersed subgingival plaque samples, which provides a differential count of bacterial morphotypes,
provided the first evidence that a correlation exists
between differential morphotype counts and the
clinical status of patients (3, 72, 75, 76, 85, 94, 103,
104, 129, 148). This method of monitoring dental
plaque destroys the structural framework of the subgingival microbiota. However, the differential morphotype count does reflect the nature of the intact
microbial community, albeit in a rather crude way.
Because the method is rapid, noninvasive and inexpensive, it has been used successfully to answer
some basic questions regarding the relationship of
plaque composition to certain clinical problems, including differentiation between periodontal health
and disease. Microscopic monitoring played a key
role in the early demonstration that mechanical debridement not only decreases plaque mass but also
radically changes the composition of the subgingival
microbiota for several weeks postoperatively (71, 78,
94). When mechanical debridement is supplemented with antibiotic therapy, spirochetes may not

The structure of dental plaque

return to baseline levels for months (130). These


findings helped to explain, in part, the lasting clinical benefits of mechanical debridement through its
effect on the subgingival microbial composition.
Microscopic monitoring of bacterial morphotypes
in patients with untreated periodontitis also provided some early insight into the differential distribution of bacteria between sites within subjects and
between subjects (37). This information is essential
for developing and optimizing sampling methods.
Despite some variability in the distribution of bacterial morphotypes between the deepest pockets in
individual patients, most of the variance originates
from samples between subjects (37). These findings
led to the conclusion that pooled samples of the
deepest pockets might be the optimal method of
sampling pockets for clinical applications. These
conclusions have been generally confirmed and extended on the basis of studies that used other experimental designs and identification methods: immunofluorescence (26) or DNA probes (48, 49, 118).
These studies have also demonstrated that the number of sampled sites required to identify the presence of a particular microorganism increases as the
prevalence and recovery level of the organism decreases.
Despite the excellent correlations that have been
described between certain periodontal conditions
and the composition of their accompanying microbiota, few investigations have demonstrated that a
given microbial population is indicative of future
clinical events. Listgarten & Levin (76) reported that
high proportions of spirochetes and/or motile rods
were predictive of disease recurrence in a treated
periodontitis population from whom maintenance
visits were withheld or were provided at very infrequent intervals (80). However, this observation
was not valid for patients with regularly scheduled
trimonthly maintenance visits, either for spirochetes
and/or motile rods (80) or for other suspected
pathogens such as A. actinomycetemcomitans, Preuotella intermedia or i? gingivalis (81). Nor was it possible to demonstrate, in patients receiving regular
prophylaxis, that sites with clinical evidence of
breakdown were microbiologically distinct from
those without discernible deterioration (77, 81).
These results, which at first may appear contradictory, are most likely due to the disruptive influence
of routine prophylaxis on plaque structure and composition, with the resulting loss of diagnostic reliability.
Today several methods are available to monitor
the periodontal microbiota. With the emergence of

certain species as likely pathogens, the emphasis is


to monitor selected species, rather than the entire
plaque population.
However, it is apparent that the mere presence of
one or more pathogenic species in a subject is insufficient to produce significant deterioration in the
periodontal status of this individual. This finding
can be explained by the multiplicity of other factors
that contribute to the clinical outcome, including
host and environmental factors as well as local bacterial interactions that can modulate the virulence of
otherwise pathogenic species (28, 73, 132, 135).
Nevertheless, in patients who have received standard periodontal therapy and exhibit evidence of
satisfactory plaque control, microbiological testing
may provide an additional and valuable diagnostic
aid for the therapist who suspects a contributing
periodontal infection and seeks some guidance with
respect to antimicrobial treatment (74). Such testing
may be of special value for older patients in a general practice, and more specifically for patients at
high risk for periodontitis. It is of little value, however, as a screening test for the general population,
particularly the younger age groups (32). As our
knowledge of periodontal microbiology increases, it
is likely that microbiological diagnosis will play an
increasingly important role in the management of
patients with infectious forms of periodontal disease.

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