INVASION OF bacteri.docx

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INVASION OF DENTINAL TUBULESBY ORALBACTERIA

1. R.M. Love1,*2. H.F. Jenkinson2

1.1

Department of Stomatology, University of Otago School of Dentistry, PO Box 6!, D"ne#in, $e%&ealan#'

2. 2Department of Oral an# Dental Science, University of Bristol Dental School, Bristol BS1 2(),Unite# ing#om

1. *correspon#ing a"thor, ro+ert.love#ent.otago.ac.n-' $ext Section

As!"#$!

Bacterial invasion of #entinal t"+"les commonly occ"rs %hen #entin is expose# follo%ing a +reach in theintegrity of the overlying enamel or cement"m. Bacterial pro#"cts #iff"se thro"gh the #entinal t"+"le to%ar# thep"lp an# evoe inflammatory changes in the p"lpo/#entin complex. 0hese may eliminate the +acterial ins"ltan# +loc the ro"te of infection. Unchece#, invasion res"lts in p"lpitis an# p"lp necrosis, infection of the rootcanal system, an# periapical #isease. hile several h"n#re# +acterial species are no%n to inha+it the oralcavity, a relatively small an# select gro"p of +acteria is involve# in the invasion of #entinal t"+"les an#s"+se"ent infection of the root canal space. 3ram/positive organisms #ominate the t"+"le microflora in +othcario"s an# non/cario"s #entin. 0he relatively high n"m+ers of o+ligate anaero+es present/s"chas Eubacterium spp., Propionibacterium spp., Bifidobacterium spp.,Peptostreptococcus micros,an# Veillonella spp./s"ggest that the environment favors gro%th of these +acteria. 3ram/negative o+ligateanaero+ic ro#s, e.g., Porphyromonasspp., are less fre"ently recovere#. Streptococci are among the mostcommonly i#entifie# +acteria that inva#e #entin. 4ecent evi#ence s"ggests that streptococci may recogni-ecomponents present %ithin #entinal t"+"les, s"ch as collagen type 5, %hich stim"late +acterial a#hesion an#intra/t"+"lar gro%th. Specific interactions of other oral +acteria %ith inva#ing streptococci may then facilitate theinvasion of #entin +y select +acterial gro"pings. n "n#erstan#ing the mechanisms involve# in #entinal t"+"leinvasion +y +acteria sho"l# allo% for the #evelopment of ne% control strategies, s"ch as inhi+itory compo"n#sincorporate# into oral health care pro#"cts or #ental materials, %hich %o"l# assist in the practice of en#o#ontics.

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*I+ In!"o'&$!ion

7n#o#ontics is the clinical #iscipline that #eals %ith the prevention an# management of #iseases of the p"lpan# periapical tiss"es. $ormally, the #ental p"lp 89ig. 1: is sterile an# is primarily involve# in the pro#"ction of #entin an# in tooth sensi+ility. 0he p"lp an# #entin form a f"nctional complex that is protecte# from exogeno"ss"+stances in the oral cavity +y the overlying enamel or cement"m. hen the p"lpo/#entin complex +ecomesinfecte# 89ig. 1:, the tiss"es react to the inva#ing +acteria in an attempt to era#icate them. 0he a+ility of the

complex to perform this f"nction sho"l# not +e "n#erestimate#, since the tiss"es are richly en#o%e# %ithimm"nocompetent processes. ;o%ever, in clinical terms, if the ro"te of infection is not era#icate# +y thesenat"ral processes, or +y operative proce#"res, then the +"r#en of +acteria inva#ing the complex overcomesthe #efenses an# ca"ses p"lp #isease, e.g., p"lpitis, necrosis, an# infection of the p"lp cham+er an# rootcanal.

:.Dental caries involving the cro%n of the tooth can affect people at any age from %hen the cro%n er"pts into themo"th. By contrast, root/s"rface caries occ"rs only %hen there has +een loss of perio#ontal attachment an#expos"re of cement"m or ra#ic"lar #entin' hence it affects mainly a#"lts. Unchece#, the a#vancing +acterial

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front of the cario"s process %ill res"lt in infection of the #ental p"lp an# root canal system, %hich %ill lea# toperiapical #isease. ;o%ever, +acteria that are associate# %ith an infecte# root canal #iffer from those primarilyassociate# %ith #ental caries. 0h"s, altho"gh streptococci an# Actinomyces are maGor components of #entalpla"e 8Heninson an# (amont, 1??!: an# may initiate t"+"le an# p"lpal infection, o+ligately anaero+ic +acteriaare commonly present in large n"m+ers in the infecte# root canal.Streptococci are the primary +acterial coloni-ers of the oral cavity, an# a#hesion of streptococci to the ac"ire#pellicle is an essential first step in coloni-ation of the tooth 8 3i++ons, 1?A?' olen+ran#er an# (on#on,

1??I' Heninson an# (amont, 1??!:. Streptococci express m"ltiple s"rface protein a#hesins 8;asty et al .,1??2: that allo% cells to +in# to a %i#e range of s"+strates fo"n# in the oral cavity, incl"#ing other micro+ialcells, salivary components, host cells, or extracell"lar matrix or ser"m components 8 Heninson an# (amont,1??!:. ;o%ever, %hile there are consi#era+le #ata on the mechanisms involve# in the formation an##evelopment of #ental pla"e 8olen+ran#er, 2:, relatively little is no%n a+o"t the mechanisms +y %hichoral +acteria penetrate or inva#e #entin, an# ca"se p"lpitis, root canal infection, an# periapical #iseases.

#vances in micro+ial sampling metho#s, an# in gro%th an# i#entification techni"es, have provi#e# m"ch ne%information on the micro+ial components an# complexes that are associate# %ith en#o#ontic an# perio#ontalinfections 8S"n#vist, 1??' Socransy et al ., 1??A:. 0his article %ill revie% c"rrent no%le#ge of themicro+iology of #entinal t"+"le infections. 5t %ill also #escri+e ho% recent #evelopments have a#vance# o"r "n#erstan#ing of the micro+ial complexity of root canal an# p"lpal infections, an# of the mechanisms +y %hichsome species of oral +acteria are a+le to inva#e #entin.Previo"s Section$ext Section

*II+ Mi$"oio%o- o( In(e$!ion o( !)e &%/o0Den!in Co/%e

*A+ ULO0DENTIN COMLE3Biologically an# #evelopmentally, p"lp an# #entin f"nction as a complex an# may +e regar#e# as one tiss"e.Dentinal fl"i# movement, res"lting in hy#ro#ynamic activation of p"lpal /#elta nerve fi+ers an# ca"sing #entinsensitivity 8BrnnstrEm, 1?A6:, is a common example of f"nctional co"pling of the tiss"es. Both tiss"es are#erive# from the #ental papilla, an# #evelopment of the t%o tiss"es is closely relate#. 0he str"ct"re an#composition of #entin matrix, an# of the #entinal t"+"les, are ey infl"ences in the process of +acterial invasionof #entinal t"+"les.0he #ental p"lp is encase# +y #entin an# occ"pies a space commonly #esignate# the p"lp cham+er in coronal#entin an# the root canal in ra#ic"lar #entin. Dentin is poro"s, har#, minerali-e# connective tiss"e compose#primarily of hy#roxyapatite/coate# collagen type 5 fi+rils. Other collagen types 8555,


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+acterial cells an# t"+"le. Bar= .C Jm. *B+ gro"p of streptococcal cells in intimate contact %ith a t"+"le %all.Bar= 1. Jm. 84epro#"ce# %ith permission from (ove et al ., 1??!.:

5ntrat"+"lar #entin is highly minerali-e# 8approximately ?C volK mineral phase: compare# %ith the less/minerali-e# collagen matrix 8a+o"t I volK mineral phase: of intert"+"lar #entin 8@arshall, 1??I:, an#+ecomes more minerali-e# %ith increasing age. 0his res"lts in a #ecrease in si-e, an# "ltimately o+literation, of the #entinal t"+"les, %ith a+o"t K #ecrease in the overall n"m+ers +et%een the ages of 2 an# A years

80ronsta#, 1?!I' >arrigan et al ., 1?A:. 0he mean n"m+ers of t"+"les at any given age %ithin coronal, cervical,an# mi#/root #entin are similar 8approximately ,2I, 2,I6, an# I?,1 mm /2, respectively: 8>arrigan et al .,1?A:. ;o%ever, significantly fe%er #entinal t"+"les are fo"n# in apical #entin 8approximately A1? mm /2:,s"ggesting that the formation of intrat"+"lar #entin occ"rs more rapi#ly in the apical region of the root.*B+ INTRATUBULAR CONTENT AND DIFFUSION ROERTIES0he composition of #entinal t"+"le fl"i# in vital #entin is not f"lly no%n' ho%ever, it resem+les ser"m %ithproteins s"ch as al+"min an# imm"noglo+"lin 3 85g3: +eing present 8n"tsson et al ., 1??:. 5n a##ition, other +loo# proteins, s"ch as fi+rinogen, may +e fo"n# in #entinal t"+"les after cavity preparation 8 n"tsson et al .,1??' 5-"mi et al ., 1??A:. Dentinal fl"i# %ithin non/vital root #entin is fl"i# originating from alveolar +one an#perio#ontal ligament, %hile #entinal fl"i# %ithin non/vital coronal #entin is liely to +e #erive# from saliva.Dentinal t"+"les may contain o#onto+last processes, nerve fi+ers, an# "nminerali-e# collagen fi+rils. Dai et al .81??1: examine# the contents of #entinal t"+"les of permanent h"man incisor, canine, premolar, an# molar teeth from patients %hose ages range# from 1A to C yrs. 0hey fo"n# that "nminerali-e# collagen %as a maGor component %ithin #entinal t"+"les, occ"rring in 6CK of all t"+"les in inner #entin 8closest to the p"lp:. 5n 16K

of these t"+"les, the collagen %as aggregate# into large +"n#les that occ"pie# more than one/fifth of thel"men. 5n mi##le #entin, the correspon#ing fig"res %ere 2 an# !K, an# for o"ter #entin, 12 an# K. 0hesepatterns of collagen #istri+"tion %ere similar for all tooth families an# %ere "nrelate# to age, s"ggesting thatcollagen is contin"ally lai# #o%n %ithin #entinal t"+"les thro"gho"t life.Dentin is very poro"s +eca"se of the t"+"lar str"ct"re. ;o%ever, the #egree of permea+ility varies +et%een#ifferent areas of a tooth an# the n"m+er of patent #entinal t"+"les present 8 Pashley, 1??:. 0he p"lpo/#entincomplex is normally protecte# from the oral cavity +y the overlying enamel or cement"m. Once caries, tra"ma,or restorative or perio#ontal proce#"res +reach the integrity of this +arrier, the t"+"les provi#e #iff"sionchannels from the s"rface to the p"lp. Bacteria can then inva#e these #entinal t"+"les, an# +acterial pro#"ctscan #iff"se across #entin to elicit p"lpal reactions 8ontin"e#stim"l"s res"lts in the p"lpo/#entin complex respon#ing to the noxio"s challenge +y activation of imm"nocompetent cells an# inflammatory processes in the p"lp an# +y #ecreasing the permea+ility of the#entin +y the pro#"ction of sclerotic or reparative #entin 8for revie%s, see Pashley, 1??6' Hontell et al ., 1??A:.hen "nchece#, +acterial invasion of #entinal t"+"les overcomes the p"lpo/#entin #efenses, res"lting ininfection of the p"lp an# root canal system.


*III+ B#$!e"i#% Inv#sion o( Co"on#% Den!in

*A+ ARIOUS DENTIN0he cariogenic microflora present on the s"rface of fiss"re, smooth/s"rface coronal, or root/s"rface cariesconsists mainly of streptococci, lacto+acilli, an# Actinomyces spp. @em+ers of the m"tans gro"p streptococci,in partic"lar S. mutans an# S. sobrinus, are consi#ere# to +e the primary etiological agents in the in#"ction of coronal an# of root caries 8Bo%#en, 1??' van ;o"te, 1??' van ;o"te et al ., 1??:. Samples of cario"s #entinfrom the o"ter s"rfaces of teeth contain Streptococcus spp.,Lactobacillus spp., Actinomyces spp. an# other

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3ram/positive ro#s 8(oesche an# Sye#, 1?!I:. Samples from the p"lpal si#e of cario"s #entin lesions of extracte# teeth contain larger n"m+ers of 3ram/positive anaero+ic ro#s of Eubacterium, Propionibacterium,an# Bifidobacterium species, %ith Actinomyces an# Lactobacillus +eing the most prevalent fac"ltative +acteriaisolate# 87#%ar#sson, 1?!:. 5n these st"#ies, streptococci constit"te# only a minor gro"p of the total isolates.0h"s, #ifferent regions of cario"s #entin may contain "ite #ifferent proportions of +acterial components in their microflora.3reater n"m+ers of +acteria are recovere# from s"perficial infecte# #entin compare# %ith #eeper #entin

8;oshino, 1?AC:. 0he application of strict anaero+ic sampling an# c"ltivation metho#s al%ays gives higher recoveries of +acteria, implying that the environment of cario"s #entin promotes s"rvival of o+ligately anaero+ic+acteria. 0h"s, species of Propionibacterium, Eubacterium, an# Bifidobacterium #ominate the microflora of #eep cario"s #entin, %ith Actinomyces, Lactobacillus, an# some streptococci, +"t rarely S. mutans, +eingpresent 80a+le 1:. 3ram/negative o+ligate anaero+es, e.g., usobacterium, are recovere# in only very lo%n"m+ers, if at all 80a+le 1:. 0o i#entify an# locali-e +acterial species %ithin cario"s #entin, O-ai et al . 81??:#etecte#, +y imm"nohistochemical techni"es, specific +acteria %ithin #entin samples from fiss"re, smooth/s"rface coronal, an# root/s"rface caries. 0hey fo"n# that m"tans gro"p streptococci %ere the pre#ominant+acteria %ithin #entin from fiss"re an# smooth/s"rface coronal caries, %ith higher n"m+ers in the shallo% an#mi##le layers of #entin compare# %ith #eep #entin. Other +acteria previo"sly i#entifie# as +eing #ominantmem+ers of the microflora of cario"s h"man #entinLs"ch as Lactobacillusspp., Eubacterium alactolyticum,an# . nucleatum 87#%ar#sson, 1?!' ;oshino, 1?AC:L%ere fre"ently #etecte#, tho"gh their relativeproportions %ere lo% 80a+le 1:. 0h"s, the environment %ithin s"perficial cario"s #entin favors gro%th of fac"ltative anaero+es that are associate# %ith the cario"s process, e.g., m"tans streptococci, %hile the

microflora #eep %ithin the #entin is #ominate# +y o+ligately anaero+ic organisms.


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p"lpal #isease 8(ove, 1??6a:. ;ence, sealing of #entin from exogeno"s s"+stances an# +acteria in the oralcavity, in +oth vital an# non/vital teeth, is a critical step in tooth restoration.

onse"ently, the +acteria that are #etecte# in the root canal m"st havegaine# entry +y inva#ing #entinal t"+"les. S"n#vist 81?!6: st"#ie# the microflora of h"man teeth that ha#+ecome non/vital as a res"lt of tra"ma, +"t %hich other%ise %ere intact an# caries/free. Utili-ing strictlyanaero+ic sampling techni"es, he #emonstrate# that +acteria co"l# not +e isolate# from teeth %ith normalperiapical tiss"e, %hile +acteria %ere reg"larly isolate# from teeth from patients %ho ha# apical perio#ontitis.(ie%ise, @Eller et al . 81?A1: sho%e# that only #evitali-e# an# infecte# p"lps of money teeth sho%e# signs of apical perio#ontitis, %hereas #evitali-e# an# "ninfecte# p"lps #i# not #evelop periapical +one #estr"ction. 0hepioneering st"#ies +y S"n#vist 81?!6: an# later +y @Eller et al . 81?A1: #emonstrate# that, in a##ition tostreptococci, lacto+acilli, an# Actinomyces, o+ligately anaero+ic species of usobacterium,Peptostreptococcus, Eubacterium,Propionibacterium, Veillonella, #olinella, Prevotella,

an# Porphyromonas #ominate# the root canal microflora 80a+le I:. Other micro/organisms s"ch asyeasts, e.g., $andida an# Saccharomyces 8(ana et al ., 21:, an# spirochetes, e.g., %reponema8H"ng et al .,2' 4as et al ., 21:, have +een occasionally recovere# from an infecte# root canal. @ost of the oxygen/sensitive mem+ers of the root canal microflora are not rea#ily c"ltiva+le %itho"t the strict application of anaero+ic metho#s 8>arlssonet al ., 1?!!:, an# this may explain %hy, in earlier st"#ies, many teeth %ith apicalperio#ontitis #i# not appear to har+or +acteria in the root canal.


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TABLE 4B#$!e"i#% S/e$ies Coon%- Fo&n' in As-/!o#!i$ In(e$!e' Roo! C#n#%s

O+ligately anaero+ic +acteria #ominate the microflora of esta+lishe# asymptomatic infecte# root canals, %ithstreptococci maing "p a significant proportion of the fac"ltative species. >ommonly, +et%een 2 an# A +acterialspecies are recovere# from infecte# root canals, %ith . nucleatum, P. intermedia, an# streptococci +eing oftenpresent 8S"n#vist, 1??' (e 3off et al ., 1??!: 80a+le I:. series of st"#ies on the #ynamics of experimental

root canal infections of money teeth has sho%n that fac"ltative anaero+ic +acteria, mainly streptococci, arethe first coloni-ers of the root canal, +"t that +y 6 months, o+ligate anaero+es #ominate the microflora. hencom+inations of +acterial strains, isolate# originally from an en#ogeno"sly infecte# root canal, %ere re/inoc"late# into f"rther canals %ith #evitali-e# tiss"e, the #ominance of anaero+ic +acteria %as againesta+lishe#. 9"rthermore, the original proportions of the +acterial strains %ere re/esta+lishe#, #espite e"aln"m+ers of the #ifferent strains +eing inoc"late# into the canals 89a+rici"s et al ., 1?A2a,+:. 0hese o+servationss"pport the notion that associations +et%een specific +acteria ena+le the root canal microflora to gro% an#s"rvive in a highly speciali-e# an# selective environment 8S"n#vist, 1??2a:.@ixe# root canal infections res"lt in larger periapical lesions than #o mono/infections 89a+rici"s et al ., 1?A2a,+:.;o%ever, %hile the components of the root canal microflora are %ell/esta+lishe#, it is interesting that no single+acterial species has +een in#icte# as the maGor p"lp an# periapical pathogen in chronic asymptomaticcon#itions. P. gingivalis, %hich is strongly implicate# in #estr"ctive a#"lt perio#ontal #isease 8Socransy an#;affaGee, 1??2' (amont an# Heninson, 1??A:, is recovere# in lo% n"m+ers from asymptomatic chronic rootcanal infections 8S"n#vist, 1??' (e 3off et al ., 1??!:. ;o%ever, n"m+ers

of Porphyromonas an# Prevotella species increase #ramatically %hen there are signs an# symptoms of ac"teperiapical infection 8;aapasalo, 1?A?' S"n#vist et al ., 1?A?' ;ashioa et al ., 1??2:. 0he #ominance of 3ram/negative species in the latter stages of root canal infection s"pports the evi#ence that a highly selectiveenvironment contin"es to #evelop %ithin the root canal system. @oreover, mechanisms may exist that allo%these 3ram/negative o+ligate anaero+es,e.g., .Porphyromonas an# Prevotella species, to penetrate #entin,even tho"gh the +acteria are not ro"tinely isolate# from the t"+"le microflora.0he microflora of cario"s an# cavitate# #entin of teeth %ith p"lpitis is similar to that previo"sly reporte# for intact cario"s #entin 8;ahn et al ., 1??: 80a+le 1:. 3ram/positive organisms pre#ominate,especially Lactobacillus spp. an# streptococci. 3ram/negative +acteria, e.g., P. intermedia, are fo"n# in lo%er n"m+ers in s"perficial to #eep #entin, +"t are more prevalent %ithin #entin at the p"lpal %all. 5nvestigating the#egree of cell"lar infiltrate an# #egenerative changes in the p"lps of teeth %ith cavitate# cario"s #entin,@assey et al . 81??I: reporte# no association +et%een the micro+ial loa# %ithin the #entin an# histopathology of the p"lp. ;o%ever, there %as a positive correlation +et%een the presence of P. intermedia an# P.melaninogenica an# extensive inflammation of the p"lp.


*V+ B#$!e"i#% Inv#sion o( R#'i$&%#" Den!in ("o !)e Roo! C#n#%

Once +acteria gain access to the root canal system, they inva#e root canal #entinal t"+"les 89ig. 1>: an# may+e responsi+le for persistent root canal infection 8 ;aapasalo an# Frstavi, 1?A!' Frstavi an# ;aapasalo,1??:. Shovelton 81?6: examine# histologically ?! extracte#, clinically non/vital teeth an# fo"n# that 61 of theteeth sho%e# +acterial penetration of the ra#ic"lar #entinal t"+"les. 0he n"m+ers of t"+"les containing +acteria%ere highly varia+le from tooth to tooth an# among sections of an in#ivi#"al tooth. 0he #epth of penetration +y+acteria into the t"+"les %as also fo"n# to +e varia+le. 5t %as note# that the presence of +acteria %ithin thet"+"les %as relate# to the clinical history of the tooth, s"ch that chronic infections ha# more +acterial invasionan# that t"+"le invasion #i# not occ"r imme#iately after the +acteria appeare# in the root canal. 0heseo+servations %ere similar to those reporte# in later histological st"#ies on the invasion of non/cario"s coronal#entin 8("n#y an# Stanley, 1?6?'BrnnstrEm an# $y+org, 1?!1' 0ronsta# an# (angelan#, 1?!1'


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#entin. 4ecently, Peters et al . 821: #emonstrate# that the flora recovere# from mi#/root ra#ic"lar #entin of teeth %ith apical perio#ontitis of en#o#ontic origin %as similar to that reporte# in previo"s st"#ies 8 n#o an#;oshino, 1??:, %hile 3ram/negative +acteria incl"#ing . nucleatum, P. gingivalis, an# P. intermedia %erecommonly recovere#. >learly, 3ram/negative o+ligate anaero+ic +acteria are more fre"ently fo"n#, an# inhigher cell n"m+ers, in infecte# root canals than in cario"s an# non/cario"s infecte# #entin. Un#o"+te#ly, theapplication of novel molec"lar techni"es that #etect +acteria in samples %itho"t the necessity for la+oratoryc"ltivation 8Dymoc et al ., 1??6:, or the presence of +acteria in situ, %ill assist greatly in f"t"re analyses of

infecte# #entin, root canals, an# p"lpal tiss"es.Previo"s Section$ext Section

*VI+ B#$!e"i#% Inv#sion o( R#'i$&%#" Den!in ("o # e"io'on!#% o$ke!

Bacterial invasion of ra#ic"lar #entin of perio#ontally #isease# teeth has +een #emonstrate# +y lightmicroscopy 8opc-y an# >onroy, 1?6A' (angelan# et al ., 1?!' #riaens et al ., 1?A!+: an# +y micro+iologicalst"#ies 8 #riaens et al ., 1?A!a' 3i"lianaet al ., 1??!:. 5t has +een s"ggeste# that the #entinal t"+"le microfloraassociate# %ith a perio#ontal pocet co"l# act as a reservoir for re/coloni-ation of the pocet after #e+ri#ement8 #riaens et al ., 1?A!a' 3i"liana et al ., 1??!:. 0he maGority of species recovere# from ra#ic"lar #entin are3ram/positive +acteria 8P. micros, S. intermedius, A. naeslundii :, %ith lo%er n"m+ers of 3ram/negativeorganisms 8P. gingivalis, P. intermedia, Bacteroides forsythus, . nucleatum, V. parvula 83i"liana et al ., 1??!:.hile it is clear that +acteria are a+le to inva#e ra#ic"lar #entin from the perio#ontal pocet, a contentio"siss"e is %hether +acteria inva#e healthy cement"m prior to #entin penetration, or if +acteria gain access to

#entin only via +reaches in the cement"m layer. Several st"#ies have #escri+e# invasion of the cement"m of perio#ontally #isease# teeth 8;art-ell, 1?11' Daly et al ., 1?A2' #riaens et al ., 1?A!a,+' 3i"liana et al ., 1??!:.;o%ever, it %as not evi#ent from any of these st"#ies if the inva#e# cement"m %as intact, healthy, or #isease#.7xpose# cement"m is a thin, often #iscontin"o"s layer 8@oso%, 1?6?:, an# commonly sho%s s"rface#efects, e.g., at sites %here SharpeyQs fi+ers attach to the cement"m matrix 8 #riaens et al ., 1?A!+:. 7xpos"reof cement"m to crevic"lar fl"i#, +acterial en-ymes, or aci#ic meta+olites may in#"ce physicochemical an#str"ct"ral alterations, s"ch as locali-e# resorptive lac"nae or #eminerali-ation 8Daly et al ., 1?A2' 7i#e et al .,1?A' #riaens et al ., 1?A!+:. 5t seems liely, therefore, that +acterial invasion of expose# cement"massociate# %ith perio#ontal #isease occ"rs after the cement"m has +een altere# +y physiological, +acterial, or environmental factors.Previo"s Section$ext Section

*VII+ B#$!e"i#% Inv#sion in vi!"o

In vitro st"#ies have examine# penetration of coronal or root #entin +y a limite# n"m+er of oral +acteria that areassociate# %ith cario"s or non/cario"s #entin. >ells of S. mutans, S. sanguinis, an# A. naeslundii have all +eensho%n to penetrate #entin #iscs in vitro 8@ichelich et al ., 1?A' @eryon et al ., 1?A6' @eryon an# Broo, 1??:.5nvasion of root #entinal t"+"les +y p"re c"lt"res of streptococci or enterococci associate# %ith root canalinfections in vivo, or %ith #entinal caries, has +een #emonstrate# histologically 8see 9ig. I: 80a+le :. 5ncontrast, invasion of #entin +y mono/c"lt"res of 3ram/negative anaero+ic +acteria is less clear, +"t invasionhas not +een generally recogni-e#. $either Bacteroides melaninogenicus ss. melaninogenicus nor P.intermedia 8 pata an# Blechman, 1?A2' Pere- et al ., 1??I: inva#e# root #entin after 21/2A #aysQ inc"+ation.On the other han#, limite# invasion +y P. intermedia has +een reporte# 8Beriten et al ., 2:, %hile P.endodontalis an# P. gingivalis +oth sho%e# lo%/level penetration of #entinal t"+"les of +ovine roots that ha#the cement"m remove# 8Si"eira et al ., 1??6:.


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invasion +y P. gingivalis %as promote# %hen co/c"ltivate# %ith S. gordonii 8(ove et al ., 2:. 0heseexperiments #emonstrate that +acteria may compete for invasion of #entinal t"+"les, an# also that they mayco/operate in invasion. Both these interactions may +e significant in #etermining the o"tcome of t"+"leinfections.Previo"s Section$ext Section

*VIII+ F#$!o"s In(%&en$in T&&%e Inv#sion - B#$!e"i#

*A+ DENTIN STRUCTUREhenever #entin is c"t or a+ra#e#, a smear layer of #e+ris forms on the instr"mente# s"rface an# pacs intothe s"perficial portion of the #entinal t"+"le. In vitro experiments s"ggest that the presence of a #entinal smear layer prevents the penetration of coronal or root #entinal t"+"les +y streptococci 8@ichelich et al ., 1?A' (ove et al ., 1??6:, an# this is confirme# +y in vivo st"#ies. Bacterial invasion of #entinal t"+"les occ"rs more rea#ily%hen the smear layer has +een remove# from the #entin, compare# %ith smeare# #entin %here the #egree of t"+"le invasion is lo% 8ollagen type 5, a maGor organic component of #entin, is recogni-e# +y oral streptococci, an# %hen a+sor+e#onto hy#roxyapatite s"rfaces, it serves as an a#hesion s"+strate 8 (i" an# 3i++ons, 1??' (i" et al ., 1??:.Strains of S. mutans are a+le to +in# to "nminerali-e# collagen an# to particles of root #entin 8 S%italsi et al .,1??I:. 0he a+ility of oral streptococci to +in# to collagen may facilitate +acterial a#hesion to expose# #entin or cement"m, an# s"+se"ently tiss"e penetration. 0he antigen 5R55 polypepti#es, expresse# on the s"rfaces of most in#igeno"s species of oral streptococci 8Heninson an# Dem"th, 1??!:, play a maGor role in me#iatinga#hesion of streptococci to collagen 8(ove et al ., 1??!:. Strains of P. gingivalis also rea#ily +in# to collagen/coate# hy#roxyapatite, an# to +ovine +one collagen 8$aito an# 3i++ons, 1?AA' $aito et al ., 1??I:. 0his +in#ingis #"e, at least in part, to the a#hesion fim+riae that +in# strongly to collagen in vitro 8$aito et al ., 1??I:.

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9im+riae are involve# in other a#hesive interactions important in host coloni-ation +y P. gingivalis, s"ch as+in#ing to salivary receptors, epithelial cells, fi+ronectin, an# other oral +acteria 8 5sogai et al ., 1?AA'3o"l+o"rnean# 7llen, 1??1' (i et al ., 1??1' (amont an# Heninson, 2:, an# in the invasion of epithelial cells 8(amont et al ., 1??C' ein+erg et al ., 1??!:.4ecent #ata have provi#e# strong evi#ence for +acterial a#hesion specificity as playing a maGor role in#etermining the invasion of #entinal t"+"les. 7xperiments "tili-ing isogenic m"tants of S. gordonii or S.mutans #eficient in the expression of antigen 5R55 polypepti#e s"rface a#hesins clearly #emonstrate that these

polypepti#es not only me#iate streptococcal +in#ing to collagen, +"t also are necessary for +acterial invasion of #entin 8(ove et al ., 1??!:. 5t seems that recognition of type 5 collagen may facilitate +acterial a#hesion to #entin89ig. 2: as %ell as a morphological gro%th response manifeste# +y long/chaining of streptococcal cells 8 (ove et al ., 1??!:. 5n s"pport of this s"ggestion, aci#/sol"+le type 5 collagen fragments completely inhi+it #entinalt"+"le penetration +y streptococci in vitro 89ig. IB:. 0hese an# s"+se"ent experiments %ith mixe# c"lt"res of oral +acteria have le# to the follo%ing mo#el 89ig. : for #entinal t"+"le invasion +y streptococci an# P.gingivalis. 5t is envisage# that antigen 5R55 family polypepti#es pro#"ce# +y S. gordonii , S. mutans, an# other oral streptococci me#iate primary +in#ing of +acteria to intrat"+"lar collagen type 5. Streptococcal gro%th an#meta+olism promotes locali-e# #eminerali-ation together %ith release of collagen pepti#es. 0he presence of these pepti#es lea#s to "p/reg"lation of antigen 5R55 polypepti#e pro#"ction 8(ove et al ., 1??!:, enhance#a#hesion, an# facilitates comm"nity gro%th %ithin an# along the #entinal t"+"les 89igs. 2, :. hile P.gingivaliscells are a+le to +in# collagen, this is not s"fficient in itself to promote t"+"le invasion +y theseorganisms in mono/c"lt"re. ;o%ever, %hen P. gingivalis cells are co/c"ltivate# %ith S. gordonii cells, invasion+y the porphyromona#s is promote#. 0his appears to #epen# "pon the specific a#herent interaction

+et%een S. gordonii an# P. gingivaliscells, me#iate# +y the streptococcal antigen 5R55 polypepti#es 8 (ove et al .,2:. 5nvasion is not #epen#ent "pon pro#"ction of maGor a#hesion fim+riae +y P. gingivalis, that +in#collagen, since isogenic P. gingivalis m"tants #efective in maGor fim+riae are still a+le to co/inva#e %ith S.gordonii 8(ove et al ., 2:. On the other han#, the antigen 5R55 polypepti#e SpaP of S. mutans +in#s only%ealy to P. gingivalis cells, an#S. mutans cells #o not allo% the invasion of #entinal t"+"les +y P.gingivalis 8(ove et al ., 2:.


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5t is liely that other +acterial interactions +et%een host proteins an# other +acteria may infl"ence t"+"leinvasion. 4ecently, it has +een #emonstrate# that #entinal t"+"le invasion an# a#hesion to collagen +y S.mutans or S. gordonii %ere inhi+ite# +y h"man ser"m, s"ggesting a protective mechanism of ser"m 8(ove,21:. 5n contrast, cells of E. faecalis, a species commonly recovere# from the root canals of faile# en#o#onticcases, maintaine# their a+ility to inva#e #entin an# a#here to collagen in the presence of ser"m 8(ove, 21:. 5t%as s"ggeste# that, follo%ing root canal therapy, this a+ility may allo% resi#"al E. faecalis cells in ra#ic"lar #entin to re/coloni-e the o+t"rate# root canal an# participate in chronic fail"re of en#o#ontically treate# teeth

8(ove, 21:. nalysis of these #ata #emonstrates that specific a#herent interactions +et%een oral +acteria may facilitatet"+"le invasion. 0he o+servations sho"l# stim"late more #etaile# investigations of other +acterial interactionsan# their role in #etermining the composition of the #entinal an# root canal microflora an# the o"tcome of en#o#ontic infections.


*I3+ S&#"- #n' F&!&"e "os/e$!s

Bacterial invasion of #entinal t"+"les an# the clinical conse"ences thereof have +een recogni-e# for over acent"ry. ;o%ever, %hile many components of the infecte# #entinal t"+"le microflora have +een i#entifie#, itseems liely that there are etiological agents of en#o#ontic infections that have not yet +een recogni-e#.@olec"lar techni"es of i#entification an# "antification %ill +e po%erf"l tools in f"t"re st"#ies of en#o#ontic

infections. Bacterial invasion of #entin occ"rs rapi#ly once the #entin is expose# to the oral environment, an# inthe early stages of infection, 3ram/positive pla"e +acteria #ominate the microflora. 0he i#entification of a#hesins that me#iate these initial interactions of +acteria %ith #entin is important for the #esign of a#hesion/+locing compo"n#s. 9or example, agents that +loc antigen 5R55 polypepti#e recognition of collagen, or that+loc the co/a#hesion/me#iating properties of antigen 5R55 protein, co"l# +e effective in controlling or preventingthe initial invasion of #entinvia the #entinal t"+"les. ith time, fasti#io"s o+ligately anaero+ic +acteria +ecomeesta+lishe# as principal components of the microflora an# can +e fo"n# %ithin the #eep #entin layers.Unchece# +acterial invasion lea#s to inflammatory p"lp #isease, root canal infection, an# periapical #isease. 5tis important, therefore, that the mechanisms of invasion an# inter+acterial a#hesion at all stages of the process+e "n#erstoo# if novel control strategies are to +e #evelope#. 0hese might incl"#e compo"n#s that are a##e#to #entifrices or mo"th%ashes, or that co"l# +e incorporate# into #ental materials, to inhi+it the +acterialinvasion of #entinal t"+"les. ith longer retention of #entition in pop"lations in many regions of the %orl#, an#increase# inci#ence of root expos"re, it is liely that infections of the p"lp an# periapical #isease %ill have%i#er clinical implications in the very near f"t"re.


A$kno6%e'en!s

%he authors gratefully ac&no'ledge the support of the (e' )ealand *ental +esearch oundation %rust and the#ellcome %rust, London.

•

Previo"s Section

REFERENCES

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2. ↵ #riaens P, 7#%ar#s >, De Boever H, (oesche H 81?A!+:. Ultrastr"ct"ral o+servations on +acterialinvasion in cement"m an# ra#ic"lar #entin of perio#ontally #isease# h"man teeth. Periodontol C?=?ITCI.

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As!"#$!7 FREE F&%% Te!

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?. ↵ BrnnstrEm @ 81?A6:. 0he hy#ro#ynamic theory of #entinal pain= sensation in preparations, caries, an# the#entinal crac syn#rome. Endodont 12=CITC!.C"ossRe(Me'%ineO"'e" #"!i$%e vi# In(o!"ieve8e o( S$ien$e

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11. ↵

>arlsson H, 9rolan#er 9, S"n#vist 3 81?!!:. Oxygen tolerance of anaero+ic +acteria isolate# from necrotic#ental p"lps. Acta -dontol Scand IC=1I?T1C.Me'%ineO"'e" #"!i$%e vi# In(o!"ieve

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1I. >o%an @, 0aylor @3, Doyle 4H 81?A6:. inetic analysis of Streptococcus sanguisa#hesion toartificial pellicle. *ent +es 6C=12!AT12AI.


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Daly >, Seymo"r 3, ieser H, >or+et 7 81?A2:. ;istological assessment of perio#ontally involve#cement"m. $lin Periodontol ?=266T2!. C"ossRe(Me'%ineO"'e" #"!i$%e vi# In(o!"ieve

1!. Da%es >, @acPherson (@D 81??I:. 0he #istri+"tion of saliva an# s"crose aro"n# the mo"th #"ringthe "se of che%ing g"m an# the implications for the site specificity of caries an# calc"l"s #eposition. *ent

+es !2=AC2TAC!.As!"#$!7 FREE F&%% Te!

1A. Delivanis PD, 9an 81?A:. 0he localisation of +loo#/+orne +acteria in instr"mente# "nfille# an#overinstr"mente# canals. Endodont 1?=C21TC2.

1?. D"ncan @H, $aao S, So+e &, ie ; 81??I:. 5nteractions of Porphyromonas gingivalis %ith epithelialcells. Infect Immun 61=226T226C.


2. ↵ Dymoc D, eightman H, Sc"lly >, a#e 3 81??6:. @olec"lar analysis of microflora associate# %ith#entoalveolar a+scesses. $lin icrobiol I=ICI!TIC2.

21. ↵ 7#%ar#sson S 81?!:. Bacteriological st"#ies on #eep areas of cario"s #entine.-dontol +evy 2C8S"ppl

I2:=1T1I. Me'%ineO"'e" #"!i$%e vi# In(o!"ieve

22. ↵ 7#%ar#sson S 81?A!:. Bacteriology of #entin caries. 5n= Dentine an# #entine reactions in the oral cavity.0hylstr"p , (each S, Vvist


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3i++ons 4H 81?A?:. Bacterial a#hesion to oral tiss"es= a mo#el for infectio"s #iseases. *ent +es 6A=!CT!6.


I. 3illaspy 9, Patti H@, Smelt-er @S 81??!:. 0ranscriptional recognition of theStaphylococcusaureus collagen a#hesin gene cna. Infect Immun 6C=1CI6T1C.


I1. ↵ 3i"liana 3, mmat"na P, Pi--o 3, >apone 9, DQngelo @ 81??!:. Occ"rrence of inva#ing +acteria in ra#ic"lar #entin pf perio#ontally #isease# teeth= micro+iological fin#ings. $lin Periodontol 2=!ATAC. C"ossRe(Me'%ineO"'e" #"!i$%e vi# In(o!"ieve8e o( S$ien$e

I2. ↵ 3o"l+o"rne P, 7llen 4P 81??1:. 7vi#ence that Porphyromonas !Bacteroides" gingivalis fim+riae f"nction ina#hesion to Actinomyces viscosus. Bacteriol 1!I=C266TC2!.


II. ↵

;aapasalo @ 81?A?:. Bacteroi#es spp. in #ental root canal infections. Endod *ent %raumatol C=1T1. C"ossRe(Me'%ineO"'e" #"!i$%e vi# In(o!"ieve

I. ↵ ;aapasalo @, Frstavi D 81?A!:. In vitro infection an# #isinfection of #entinal t"+"les. *ent +es 66=1I!CT1I!?.


IC. ↵ ;ahn >/(, Overton B 81??!:. 0he effects of imm"noglo+"lins on the convective permea+ility of h"man#entine in vitro. Arch -ral Biol 2=AICTAI.

Me'%ineO"'e" #"!i$%e vi# In(o!"ieve8e o( S$ien$eI6. ↵

;ahn >/(, 9aller Hr, @inah 37 81??:. @icro+iological st"#ies of cario"s #entine from h"man teeth %ithirreversi+le p"lpitis. Arch -ral Biol I6=1!T1CI.

I!. ↵ ;art-ell 0 81?11:. 0he practical s"rgery of the root s"rface in pyorrhea. *ent $osmos CI=C1ITC21.

IA. ↵ ;ashioa , )amasai @, $aane , ;ori+a $, $aam"ra ; 81??2:. 0he relationship +et%een clinicalsymptoms an# anaero+ic +acteria from infecte# root canals. Endodont 1A=CCATC61. Me'%ineO"'e" #"!i$%e vi# In(o!"ieve8e o( S$ien$e

I?. ↵ ;asty D(, Ofe 5, >o"rtney ;S, Doyle 4H 81??2:. @"ltiple a#hesins of streptococci.Infect Immun 6=21!T21C2.

FREE F&%% Te!

. ↵ ;ill P7, nox , Schamsch"la 43, 0a+"a H 81?!!:. 0he i#entification an# en"meration of actinomyces frompla"e of $e% 3"inea in#igenes. $aries +es11=I2!TIIC. Me'%ineO"'e" #"!i$%e vi# In(o!"ieve

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