1 s2.0 S0165247814001874 Main PDF

Immunology Letters 162 (2014) 22–38
Contents lists available at ScienceDirect
Immunology Letters
journal homepage: www.elsevier.com/locate/immlet
The oral microbiome and the immunobiology of periodontal disease

and caries
Massimo Costalonga a,∗ , Mark C. Herzberg b,c
a
Division of Periodontology, Department of Developmental and Surgical Sciences, School of Dentistry, University of Minnesota, Minneapolis, MN 55455,
United States
b
Department of Diagnostic and Biological Sciences, School of Dentistry, University of Minnesota, Minneapolis, MN 55455, United States
c
Mucosal and Vaccine Research Center, Minneapolis VA Medical Center, Minneapolis, MN 55417, United States
a r t i c l e i n f o a b s t r a c t
Article history: The composition of the oral microbiome differs from one intraoral site to another, reflecting in part the
Available online 8 November 2014 host response and immune capacity at each site. By focusing on two major oral infections, periodontal
disease and caries, new principles of disease emerge. Periodontal disease affects the soft tissues and bone
Keywords: that support the teeth. Caries is a unique infection of the dental hard tissues. The initiation of both dis-
Periodontitis eases is marked by an increase in the complexity of the microbiome. In periodontitis, pathobionts and
Caries
keystone pathogens such as Porphyromonas gingivalis appear in greater proportion than in health. As a
Microbiome
keystone pathogen, P. gingivalis impairs host immune responses and appears necessary but not sufficient
Pathogenesis
to cause periodontitis. Historically, dental caries had been causally linked to Streptococcus mutans. Con-
temporary microbiome studies now indicate that singular pathogens are not obvious in either caries or
periodontitis. Both diseases appear to result from a perturbation among relatively minor constituents
in local microbial communities resulting in dysbiosis. Emergent consortia of the minor members of the
respective microbiomes act synergistically to stress the ability of the host to respond and protect. In peri-
odontal disease, host protection first occurs at the level of innate gingival epithelial immunity. Secretory
IgA antibody and other salivary antimicrobial systems also act against periodontopathic and cariogenic
consortia. When the gingival immune response is impaired, periodontal tissue pathology results when
matrix metalloproteinases are released from neutrophils and T cells mediate alveolar bone loss. In caries,
several species are acidogenic and aciduric and appear to work synergistically to promote demineraliza-
tion of the enamel and dentin. Whereas technically possible, particularly for caries, vaccines are unlikely
to be commercialized in the near future because of the low morbidity of caries and periodontitis.
© 2014 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
1. Introduction cavity is the surface of the tooth or tooth enamel (Fig. 1). This
non-shedding surface supports the growth and maturation of a
The digestive system begins with the oral cavity where food complex microbial biofilm. The nutrient foundations of the micro-
and microorganisms are introduced, mixed with salivary proteins biota surviving on mucosae or within the tooth biofilm are the
and digestive enzymes, swallowed, and enter the lower gastroin- proteins and glycoproteins of saliva, and the carbohydrates, pro-
testinal (GI) tract to be further digested. In the oral environment, teins and lipids of dietary food. Since the teeth are anchored to
several unique ecological niches can be mapped where microor- the jaws, but grow out of the gums or gingivae, serum proteins
ganisms establish in consortial communities. Failing to establish that exude at the gingival sulcus (the junction of the tooth and the
in oral communities, some environmental microorganisms simply gingiva; Fig. 2) are an additional source of nutrients in specific eco-
transit to the lower GI tract. logical niches. In this review, we will discuss the composition of
Despite continuous shedding of superficial epithelial layers, the the microbiota that has shed from oral surface niches into saliva,
oral mucosae are persistently colonized by microorganisms grow- biofilm communities on the tooth enamel, and within gingival sul-
ing in unique ecological niches. One distinctive feature of the oral cus. The current literature reveals that contrary to what occurs
in the GI tract, initiation of oral infectious diseases and disease
status are associated with increased diversity and richness of the
∗ Corresponding author at: 515 Delaware St SE, Rm 7-368 MoosT, Minneapolis, microbiota. Oral health is associated with low diversity and rich-
MN 55455, United States. Tel.: +1 612 626 2466. ness within the microbial community. This review also highlights
E-mail address: [email protected] (M. Costalonga). the host response to the oral microbiomes in specific niches by
http://dx.doi.org/10.1016/j.imlet.2014.08.017
0165-2478/© 2014 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
M. Costalonga, M.C. Herzberg / Immunology Letters 162 (2014) 22–38 23
(http://www.homd.org/). HOMD stores 34,753 filtered cloned

sequences representing a wide variety of healthy and diseased sites
throughout the oral cavity such as the dorsum of the tongue, lat-
eral sides of the tongue, buccal fold where the gingiva folds into
the cheek, surface of the cheeks (buccal mucosa), hard palate, soft
palate, labial gingiva, tonsils, and supragingival and subgingival
plaques from tooth surfaces (Fig. 1) [2,3]. As a system open to the
environment, accounting for 100% of the organisms found in the
oral cavity can potentially include all of the organisms in nature.
Classified as operational taxonomic units (OTUs), the organisms of
the oral cavity will differ among individuals, reflecting diet, sam-
pling times of day, and geographical locations. From a data-driven
perspective, the HOMD 34,753 clones yielded 1179 OTUs; 875 OTUs
comprise 99% of the clones. The remaining 1% or 347 clones repre-
sent 304 OTUs, comprising organisms rarely retrieved from the oral
cavity. As of March 2014, HOMD stores 688 taxa, of which 343 are
named species, 101 are unnamed cultivated microorganisms and
243 are uncultured phylotypes [4]. The relative abundance of the
oral microbiome at the genus level stored in HOMD is presented in
Fig. 1. Anatomy and ecological niches of the oral cavity.
Fig. 3 (reviewed in [5]).
Representing a minimally redundant collection of OTUs reg-
consideration of the immunopathogenesis of periodontal disease ularly found in the oral cavity (the “core” microbiome), CORE
and the immune defenses against caries. (http://microbiome.osu.edu/) is another sequence database com-
plementary to HOMD (Fig. 4) [6]. The CORE database contains 636
2. The CORE oral microbiome today phylotypes; each phylum was defined to contain DNA sequences
that are 98% similar. At this level of similarity, patterns of variation
Many basic observations of the composition of the oral due to sequence artifacts could be distinguished from heterogene-
microbiome were formulated well before ribosomal RNA-based ity among paralogous operons and the co-existence of similar but
systematics. Unachievable with classical methods, however, the differentiated taxa [7]. Of the 636 phylotypes, 365 presently lack a
power and scope of molecular taxonomy have resulted in the dis- cultured member and none of which is a singleton sequence. Sin-
covery of new phylotypes and, more importantly, a high level of gleton sequences are unique with no overlap with other sequences
bacterial community analysis that had been hypothesized [1]. to generate the contig, or with so many overlaps that cannot
Today, one of the most important databases of taxa present in be assembled to be assigned to any particular phylum. Interest-
the oral cavity is the Human Oral Microbiome Database (HOMD) ingly, 1000 pyrosequencing reads were compared from subgingival
Fig. 2. Microbial diversity and richness in periodontal health and disease. Microbial communities with lower diversity and richness harbor keystone pathogens, symbionts
and pathobionts at very low frequency and in proportions adequate to ensure health. When environmental perturbations occur in the periodontal tissues (e.g., trauma or
idiopathic growth of a keystone pathogen) or the host is genetically susceptible, keystone pathogens elicit inflammation that changes the nutrient foundation of the ecological
niche (i.e. periodontal pocket). The altered nutrient foundation promotes the proportional expansion of pathobionts relative to symbionts, promoting inflammation that
ultimately leads to connective tissue and bone destruction. Diversity and richness are higher.
24 M. Costalonga, M.C. Herzberg / Immunology Letters 162 (2014) 22–38
Fig. 3. Proportions of oral microorganisms in the Human Oral Microbiome Database (HOMD) [5].
samples of 24 patients, sequences were more effectively assigned to periodontal disease also appeared to change little in the face of sig-
existing taxa by both CORE and HOMD than the Ribosome Database nificant dietary changes and the advent of antibiotics [10]. From
Project or GenBank [6]. early humans to modern times, subtle trends include a decrease
in non-pathogenic clostridia taxa and members of the Ruminoci-
3. Oral microbiome modulated by dietary habits ccaceae family, and an increased frequency of caries-associated
Veillonellaceae, Lachnospiraceae, and Actinomycetales. Notably, the
The members of the oral microbiome in health or disease appear frequency of S. mutans is significantly higher in modern samples
to select depending on the availability of nutrients (reviewed in than in preindustrial agricultural samples [9]. It is reasonable to
[8]). Diet of the human host appears to shape the symbiosis of the point out, however, that DNA sequences buried in ancient calcu-
microbiota residing on the mucosae and on the non-shedding sur- lus sampled to compare to modern viable microbiomes may not
faces of teeth. A simple example is the use of refined carbohydrates be representative of the loose plaque biofilm directly facing the
in the diet of modern humans. Sucrose contributes to increased risk epithelium of the periodontal pocket or sites on the tooth surface
of caries. that are susceptible to caries.
Shifts in the diet of early human ancestors to modern foods Clearly, the environment and perhaps host genetics modify the
have contributed to subtle changes in the oral microbial commu- oral microbiome. In South American Amerindians living in a remote
nity. The oral microbiome of Neolithic hunter-gatherers appeared village of the Amazon forest, who are less exposed to selective
surprisingly stable over the millennia to medieval times in pressures of modern diet and are genetically less diverse than mul-
the proportional composition of different phyla [9]. Although tiracial and multiethnic urban societies, show a more restricted
small changes were detectable in the composition of the micro- oral mucosal microbiome than urban people. Despite the lower
biota between hunter/gatherers, early agriculturist humans, and number of genera identified, the Amerindians harbor an increased
medieval humans, shifting dietary habits was generally associated frequency of previously unclassified Proteobacteria [11]. Similarly,
with a decrease in microbial diversity. Interestingly, periodontal remote Eskimo tribes showed low prevalence of periodontal dis-
disease-associated taxa, including Porphyromonas gingivalis and ease and caries [12] until modern diets were introduced [13],
members of the Tannerella and Treponema genera, were more whereas Sri Lankan tea workers with diets essentially identical to
prevalent in the farming than hunter-gatherer populations. The early ancestors and in the absence of conventional oral hygiene
decrease in microbial diversity culminated in dramatic shifts in the measures had little caries but showed a range of incidence and
proportional composition of the microbial communities of humans severity of periodontitis as people aged in a landmark longitudinal
of the industrial revolution. In contrast, from medieval to modern study [14]. In the Sri Lankan population, the severity of periodonti-
times, the oral microbiome associated with the gingival sulcus and tis appeared to reflect the presence of putative pathogens in the
Fig. 4. CORE microbiome of oral cavity. The tree was generated with RAxML BlackBox Web server [154] and viewed in ITOL [155]. Genera are color-coded by phyla, except
for the Firmicutes and Proteobacteria, which are shown at the level of class. (For interpretation of the references to color in this figure legend, the reader is referred to the
web version of this article.)
Source: Adapted from Griffen et al. [6].
subgingival microflora [15]. Since the Sri Lankans employed no tongue harbor a microbiota skewed toward anaerobic genera such
oral hygiene measures and enjoyed similar diets, host genetic poly- as Prevotella and Veillonella, whereas the ventral surface bears a
morphisms within racially and ethnically similar populations may microbiota rich in streptococci and Gemella [19]. Consistent with
account for differences in acquisition or outgrowth of pathogens the contribution of the shedding biofilm from the tongue, the sali-
and the occurrence of disease. vary microbiome has been reported to contain a number of genera
During the past few hundred years, the human mouth appears with the most prevalent or autochthonous being Prevotella and
to have become a substantially less biodiverse ecosystem. Since Streptococcus (Fig. 5) [20]. Genera present at <1% prevalence are
higher phylogenetic diversity is associated with greater ecosystem considered transients or allochthonous microorganisms.
resilience [16,17], the decreased diversity of the modern oral envi-
ronment may be associated with less resistance to perturbations
and greater susceptibility to insertion of pathobionts or even true 4.2. Saliva and salivary constituents
pathogens in the microbial community [9]. Whereas this hypothe-
sis has yet to be tested, the microbiota of different ecological niches The tissues and surface biofilms of the oral cavity are constantly
within the oral cavity may reflect greater or less stability over time. immersed in saliva. The myriad proteins and glycoproteins in saliva
provide lubrication for mastication and gustatory sensation, and
both support and antagonize biofilm formation [21]. In conditions
4. Characteristics of different oral ecological niches
of nutrient deprivation, bacteria in the oral milieu show consortial
behavior to facilitate metabolism of specific salivary glycoproteins
In defining health and disease or the microbial communities
as a nutrient source [22]. A salivary film conditions the enamel of
that prelude the establishment of caries or periodontal disease, it is
the tooth crown. In the salivary film, salivary proteins (glycopro-
critical to define the characteristic microbiota within specific eco-
teins) are available to interact with microbial adhesins of pioneer
logical niches. In the broadest terms, the oral cavity harbors at least
colonizers as modeled in vitro, facilitating the initiation of biofilm
five communities: the teeth, which are non-shedding surfaces; the
formation on the tooth surface [23–25]. Expression of adhesins is
saliva; the dorsal and lateral surfaces of the tongue; and the gingi-
dynamic and responsive to the adhesion status of the pioneer col-
val sulcus and the periodontal pocket; and the remaining epithelial
onizer [26]. As the salivary film transitions from the crown into
surfaces of the oral mucosae [2,18].
the gingival sulcus, the composition changes and the proportion
of serum proteins increases due to the proximity with the gin-
4.1. Salivary microbiome gival crevicular fluid (GCF) (Fig. 2) [27]. With the adsorption of
serum proteins, the composition of the dental biofilm also changes
Saliva has no indigenous microbiota. The bacteria in saliva are from predominantly pioneer Streptococci and Actinomyces spp. to
those shed from biofilms on oral tissues. All epithelial surfaces an increased proportion of putative periodontal pathogens.
desquamate, releasing associated bacteria into the bathing saliva. Salivary proteins (glycoproteins) that affect oral biofilm forma-
The salivary microbiome consists disproportionally of microor- tion include secretory IgA [28], mucins [29], agglutinin (GP340)
ganisms from the tongue biofilm. The papillate surfaces of the [30], and proline-rich proteins [31,32]. These proteins can promote
Fig. 5. Proportions of different genera recovered from whole saliva of healthy adults. Saliva was collected from a group of 71 healthy individuals by mouthrinse with 10 mL
UV-irradiated sterile saline for 30 sec and stored at −80 ◦ C. The asterisks (*) denote the best classification possible as adapted from a table in [20].
microbial adhesion because the salivary film and its constituent formation, the surfaces of the teeth are more complex than the
proteins coat the teeth and mucosal membranes [33]. Also present hydroxyapatite mineral of the enamel forming the crowns and the
as fluid-phase salivary constituents, however, the constituent cementum, which coats the roots. The tooth enamel in the mouth
proteins also appear to promote desorption, agglutination and is coated with a salivary film, whereas the roots can be coated
microbial clearance by swallowing of saliva. Indeed, saliva is with an admix of salivary and serum proteins. The protein-rich
swallowed at the rate of ∼1 mL per minute. The constituent antimi- films are the actual sites of initial adhesion of the pioneer micro-
crobial proteins and peptides of whole saliva include cystatins [34] bial colonizers (reviewed in [33,41]. Pioneer streptococcal adhesins
and histatins [35,36], lysozyme, lactoferrin and lactoperoxidase initially bind the salivary film of the enamel via “catch-bond” or
[37], defensins [38], cathelicidin [39], and calprotectin (S100A8/A9) shear-enhancement interactions, requiring sheer-induced confor-
[40]. The antimicrobial proteins/peptides all likely limit the over- mational changes in the adhesins [42]. As the biofilm matures, the
growth of many species in the dental biofilm. community becomes more complex. During maturation, the chang-
ing architecture of the dental plaque biofilm reflects the forces of
4.3. Microbiota on teeth interspecies coaggregation more than new interactions between
early tooth colonizers with the salivary film (Fig. 6) [43].
Unlike the shedding surfaces of the oral epithelia, the tooth The dental plaque microbial community that forms on the
surfaces are the only “non-shedding” surfaces in the oral cavity. enamel salivary film (supragingival; above the gum line) differs
The non-shedding surfaces facilitate a stable anchoring location from the subgingival (below the gum line) community, which
for long-term biofilm development. As a substrate for biofilm forms on the proteinaceous film that coats the cementum of the
Fig. 6. Selective coaggregation and relative abundance of microorganisms in supra/subgingival dental plaque of humans. (A) Spatial analysis of human dental plaque using
Combinatorial Labeling and Spectral Imaging – Fluorescence In Situ Hybridization (CLASI-FISH) strategy reveals specific interactions between certain microorganisms and
not with others. (B) The 2D plot reveals the relative abundance (diameter of circles) and intertaxon associations observed between labeled taxons. A line connecting two taxa
indicates that cells of the lower-abundance taxon of any pair were observed to associate with cells of the higher-abundance taxon with >3% frequency and more frequently
than would be expected from random associations.
Source: Adapted with permission from Valm et al. [43].
root. As the growth of the community extends along the root and dissimilar from saliva and further contributes to the proportional
away from the salivary environment, the film contains more serum composition of the microbiota. The microbiota in the approximal
and less saliva. The environment becomes more anaerobic and area differs from other flat surfaces of the crown or the chewing
increasing shielded from foodstuffs and extremes in pH and tem- surfaces where the enamel forms pits and fissures. Therefore the
perature. Surface sheer is reduced. Consequently the subgingival composition of the tooth microbiota is influenced not only by the
and supragingival communities differ in the proportion of faculta- location of the tooth within the mouth and the proximity to salivary
tive bacteria. flow from nearby ducts, but also by the anatomy and physiology of
The microbiota of the tooth surface (crown) has a composi- the tooth surface and the surrounding gingiva (Fig. 8).
tion slightly different than the saliva with Streptococcus ssp. and Hence, the undisturbed and more established ecological niches
Veillonella being the most prevalent (Fig. 7). These frequency dis- of the tooth display more diverse communities [18,45]. Since more
tributions among the different taxa however should be considered established and undisturbed microbial communities are more sus-
in light of the method of analysis. Cloning and sequencing of 16s ceptible to caries, these findings seem to contradict the earlier
rRNA genes and pyrosequencing of the different V (variable) regions hypothesis established for the intestine, where a less diverse com-
of 16s rRNA genes have different levels of bias in amplifying such munity is more permissive to the insertion of new pathogenic taxa
variable rRNA sequences [44]. [17].
4.4. Ecological niches on the crown of the tooth 4.5. Gingival sulcus and periodontal pocket
The tooth crown can be further divided in five distinct areas The gingival sulcus and periodontal pocket form unique eco-
and ecological niches, each characterized by specific caries risks: logical niches for microbial colonization. The gingival sulcus or
the occlusal or chewing surface; the approximal surface or con- crevice is a space between the enamel of the tooth crown and the
tact point between teeth; the supragingival surface; the buccal or epithelium of the visible gingiva that folds to create an epithelial-
cheek-contacting surface; and the lingual surface approximating lined crease around the tooth (Fig. 2). Superficially the sulcus or
the tongue (Fig. 1). pocket opens into the oral cavity, whereas the base of the trough
Occlusal and approximal surfaces are the most susceptible to is bounded by a thin, modified epithelium (junctional epithe-
caries. These ecological niches harbor microbial communities that lium), which ends where the connective tissue bundles attach to
are acidogenic, producing organic acids, and/or aciduric and able the cementum surface of the root [46]. The sulcular and junc-
to withstand an acid environment. Plaque community diversity is tional epithelia are immunologically active sensors of the proximal
greater on the approximal and lingual (tongue) surfaces of molar dental plaque biofilm, expressing Toll-like receptors and other
teeth, and less diverse on buccal (cheek) and anterior or front pathogen recognition receptors (PRR) on the lining stratified squa-
teeth [18,45]. The approximal surfaces are protected from regular mous, keratin-17-positive epithelial cells [47]. The keratinocytes
toothbrushing and more susceptible to caries development. Plaque of the gingival epithelium connect to one another through desmo-
stagnates in these sites; the resident microbiota is bathed, however, somes and cell adhesion molecules such as CEACAM1 [46]. The
in a serum-like exudate. This exudate, gingival crevicular fluid, is junctional and sulcular epithelia release chemotactic molecules
Fig. 7. Proportions of different genera recovered from dental plaque of healthy adults. Supragingival plaque from a group of 98 healthy individuals by sampling cheek-side
dental surfaces using a sterile, DNA-free wooden toothpick and stored at −80 ◦ C. The asterisks (*) denote the best classification possible as adapted from a table in [20].
such as IL-8 (CXCL8) MCP-1 [48], CCL28, secretory leukocyte pro- in the gingival tissues activates neutral proteases, elastases [62],
tease inhibitor (SLPI) [47,49] and RANTES [50]. These cytokines collagenases [63] and metalloproteinases [64] destroying the
and chemokines signal neutrophils and monocytes to transmigrate epithelial and connective tissue attachments to the tooth. In an
through the epithelium into the sulcus or pocket [51]. Microbe- apparent attempt to heal, the junctional epithelium responds to the
associated molecular patterns (MAMPs) from the biofilm activate damage by migrating toward the apex of the tooth. Some work-
the epithelium, increasing the proliferative rate, expression of ers suggest that apical migration of the junctional epithelium is
adhesion molecules [47], and production of IL-1␤ [52] and antimi- stimulated by proteolytic activity from degranulating neutrophils
crobial proteins and peptides such as calprotectin and defensins within the gingival crevice [65]. As the sulcus deepens due to the
[53] (reviewed in [54]). This mixture of immune and inflammatory loss of connective tissue attachment to the root of the tooth a
mediators and white cells is contained in the gingival crevicular periodontal pocket forms. An anaerobic environment characterizes
fluid (Figs. 2 and 8) (reviewed in [55]), which brings serum pro- deep periodontal pockets with a pH range from 6 to 8 [66]. Ulti-
teins such as IgG and albumin and cytokines such as IL-1␤, IL-6, mately, the microbial biofilm in the gingival sulcus and periodontal
TNF␣ into the microbial biofilm and oral environments. pocket elicits inflammation in the surrounding connective tissue.
The gingival crevicular epithelium [56,57] and PMNs [58] Characteristic of periodontitis, this chronic inflammatory process,
express antimicrobial proteins including S100A8/A9. In the extra- ultimately drives the destruction of the alveolar bone that supports
cellular environment, S100A8/A9 appears anti-microbial when the tooth in the socket (Fig. 2) [67,68].
incorporated in neutrophil extracellular traps (NETs) [58,59]. When
present in the cytoplasm of the mucosal epithelial cells, S100A8/A9 5. Periodontal microbiome and immunity
contributes to innate intracellular immunity, protecting against
invasive bacterial pathogens [60,61]. Employing S100A8/A9, there- 5.1. Microbiota of periodontal health
fore, the gingival crevicular epithelium forms a barrier against
invasive bacteria using innate intracellular immunity and extra- The microbiota of the healthy gingival sulcus or crevice
cellular NETs. has recently been defined by pyrosequencing of V1-2 and V4
The microbiota of the dental plaque biofilm drives the regions of 16S rRNA genes [45,69]. In healthy gingival sulci (less
inflammatory process. In susceptible individuals, inflammation than 4 mm deep), the phylum Proteobacteria, particularly the
Fig. 8. Diversity and richness of microbial communities directly relate to caries risk. Microbial communities of the tooth surface and irregularities in the enamel differ with
respect to diversity and richness. Surfaces and sites with highest diversity and richness mature at ecological niches most susceptible to caries. When caries is established,
the acid environment reduces the diversity and richness of the local microbiota.
gammaproteobacteriae of genus Acinetobacter, Haemophilus and progression of the disease. Defined historically as microorganisms
Moraxella, were most prevalent. Within the phylum Firmicutes, of the “red complex” by Sigmund Socransky, P. gingivalis, Tan-
the class Bacilli comprising genus Streptococcus, Granulicatella and nerella forsythia (formerly Bacteroides forsythus) and Treponema
Gemella were also health-associated (Figs. 9 and 10). These gen- denticola were considered the cultivable microorganisms most
era can be considered symbionts, which also return to periodontal associated with disease as defined by deep periodontal pockets
pockets in high proportion after periodontal treatments [70]. [76]. Although present in low numbers in healthy subjects [77,78],
In the gingival sulcus, the conditions of ecological niche are these species were considered to be responsible for initiation and
driven from steady state by host and microbial perturbations. progression of disease. After periodontal treatment, the red com-
Through the crevicular fluid, the host dispenses isotype-switched plex microorganisms disappear (below the limits of detection).
immunoglobulins [71] specific for components of the microbiota When inflammation and deep pockets reappear, the red complex
[72,73]. Perturbations in the microbial community are also caused is again prominent. A cluster of species with less stringent associa-
by growth of microorganisms such as P. gingivalis, which can alter tion with disease was defined as the “orange complex” and includes
the nutrient foundation of the niche and disrupt the equilibrium Prevotella spp., Fusobacterium spp. and Parvimonas micra (for-
between symbionts and pathobionts (Fig. 2) (reviewed by [74]). merly Peptostreptococcus micros). The red and orange clusters and
The community is also susceptible to modulatory effects of bacte- their association with periodontitis were originally characterized
riophagic activity [75]. Hence, both host-induced species-specific by culture studies and more recently confirmed using DNA-DNA
suppression and interspecies microbial competition can increase hybridization.
the pathogenic potential of the complex, mixed-species dental Newly identified microorganisms have also been associated
plaque community. with progression of periodontal disease using more contemporary
sequencing technology. In earlier studies using cloning and Sanger
5.2. Microbiota of periodontal disease sequencing [78–80], the complexity of the dental plaque ecosys-
tem could not be ascertained because the expense of sequencing
Since the 1950s, the microbiota of the periodontal pocket limited the genetic information that could be obtained. The
has been studied with culture methods. Investigators sought power to comprehensively study bacterial community composition
to define the microbial species critical for the initiation and through determination of thousands of sequences per sample was
Fig. 9. Microbiome of the periodontal pocket in health and disease. Subgingival samples were collected from pockets <4 mm (healthy) or >5 mm (diseased) in depth. After
the removal of supragingival plaque and drying the target sites, samples were collected by insertion of four medium paper points for 10 s into three sites. Deep and shallow
sites were sampled separately in subjects with periodontitis.
Source: Adapted with permission from Griffen et al. [69].
facilitated by the advent of 454 pyrosequencing of V regions The presence of Koch’s postulate-fulfilling “true” pathogens is not
of 16S rRNA genes [18,20]. When V1-2, V4-6 and V7-9 regions apparent (Fig. 10).
are assessed, differences are observed at all phylogenetic levels Generally microorganisms associated with pockets deeper than
between health- and periodontitis-associated bacterial communi- 4 mm are reduced to very low or even undetectable levels after
ties (Figs. 9 and 10) [44,69,81]. periodontal treatment. Scaling and root planing (“deep cleaning”)
Using pyrosequencing, the microbiota highly associated with or periodontal surgery, disrupt the microbiota of the periodontal
diseased pockets greater than 4 mm in depth included the phyla pocket by mechanically scraping the biofilm off the root surface to
Spirochaetes genus Treponema, Synergistetes genus Sinergistes [82], a point that the microbial richness and biodiversity are significantly
and Bacteroidetes such as genera Porphyromonas, Prevotella and decreased [70]. Antibiotic treatments alone or in combination with
Tannerella. The class of Fusobacteria genera Fusobacterium and Lep- scaling and root planing disrupt the relative proportions of the taxa
totrichia was also highly associated with disease. As the level within the community. However, when the selective pressure is
of disease increased as measured by deeper pockets, the class lifted, the community tends to return to equilibrium without per-
Negativicutes genera Seleomonas and Megasphera appeared most sistence of antibiotic resistance in the various taxa [85].
prevalent [69,79,83,84] and Clostridia became prominent includ-
ing the genera Filifactor, Lachnospiraceae and Peptostreptococcus. In 5.3. Other domains of life
deeper diseased sites, also associated was the class Erysipelotrichia
genera Erysipelothrix, Solobacterium and Bulleidia [69,83]. Bacteria are not the only microorganisms present in the
New sequencing technologies also facilitated novel associations periodontal pocket. Members of the Archaea domain have also
between periodontitis and previously uncultivable or previously been described in the subgingival biofilm (reviewed in [86]).
underappreciated species, including the Gram-positive Filifactor Methanobrevibacter oralis phylotypes SBGA-1 and SGBA-2 are
alocis [69] and Peptostreptococcus stomatis, and species from the detected in a subset of severe periodontitis patients who har-
genera Prevotella, Synergistes [82], Megasphaera, Selenomonas, and bor low levels of Treponema spp [87]. Treponema spp. and
Desulfobulbus [3,79]. Many of these newly recognized organisms Methanobrevibacter spp. are potential syntrophic competitors. Both
correlate with disease as strongly as the classical red complex bac- are hydrogenotrophic and synthesize organic acids (acetogenic)
teria (Fig. 10). Clearly, periodontitis is a polymicrobial infection using CO2 and H2 in anaerobic conditions [88]. Potential users of H2
resulting from the expansion of pathobionts within the micro- derived from the fermentation processes of other anaerobic bac-
bial community. The expansion appears to be initiated by low teria in the subgingival plaque biofilm in deep pockets of severe
prevalence microorganisms capable of modulating the nutrient periodontitis patients include methanogenic archaea (mcrA gene)
foundation of the community through induction of inflammation, and sulfate-reducing bacteria (dsrAB gene) such as Desulfovibrio and
extravasation of blood born nutrients and serum proteins (Fig. 2). Desulfubulbus [69,89].
Fig. 10. Frequency distribution of periodontal microorganisms in periodontitis patients with ≥4 mm pockets and in healthy individuals. Data show differences between
health and disease at level of phylum, genus and species. Pie charts indicate the number of taxa that were significantly different. The graphs show levels for genera that were
≥0.1% different and species that were ≥0.2% different in health and periodontitis samples. Taxa were sorted according to magnitude of change. P ≤ 0.05 after FDR correction
for all taxa shown.
Source: Adapted with permission from Griffen et al. [69].
Viruses have also been hypothesized to contribute to the appear to drive differentiation of Th phenotypes against keystone
microbiome of the periodontal pocket. The hypothesis posits that pathogens [102].
subgingival bacteria and viruses infecting the adjacent periodon-
tal tissues would form a pathogenic consortium. Epstein–Barr
virus type 1 (EBV-1) infects periodontal B-lymphocytes and
human cytomegalovirus (HCMV) infects periodontal mono- 6.1. Polymicrobial synergy and dysbiosis hypothesis
cytes/macrophages and T-lymphocytes. EBV-1, HCMV and other
herpesviruses are present more frequently in periodontitis lesions Periodontal disease is a polymicrobial infection. It is likely that
and acute necrotizing ulcerative gingivitis-lesions than in gingivitis members of the microbiome show consortial behavior to initiate
or periodontally healthy sites [90]. Although plausible, this hypoth- and cause progression of periodontitis. For example, conventional
esis of viral consortial or cooperative pathogenesis in periodontal rodents (not germ-free) develop inflammation and periodontal
disease has never been tested definitively. bone destruction when silk ligatures are placed around their teeth
[103]. In contrast, germ-free rodents are not susceptible to peri-
odontal destruction even when placing silk ligature around teeth
5.4. Challenges sampling the periodontal pocket [103]. In rodents and humans, periodontitis appears to be a disease
in which host immunity activates by outgrowth of multiple bac-
The periodontal plaque biofilm harbors different constituents terial species within the biofilm community. Although the direct
in the loose superficial plaque and in plaque most adherent to pathogenic effects of the bacteria remain unclear in vivo, evidence
the root surface [91]. Given the small space, applying precise sam- suggests that collateral damage from the host response to the infec-
pling methods is a challenge. Depending on the sampling method, tion ultimately destroys the periodontal structures that support the
different clades of microorganisms from the “same site” can be tooth.
identified because of inadvertent sampling of proximal ecological To explain the occurrence of periodontitis without one or
communities [92]. Given the anatomy, the crude sampling tools for more emergent pathogens, the dysbiosis hypothesis has been
the periodontal pocket such as curettes and paper points yielded recently proposed [104]. The dysbiosis hypothesis maintains that
similar results. Sub-sites or communities could not be resolved. the transition from periodontal health to disease reflects changes
Nonetheless the subgingival biofilm is characterized by specific in abundance of low-abundance species in the bacterial commu-
aggregation patterns or co-colonization between different genera nity of the periodontal pocket. This shift in the composition of
[43]. It is important to note that in diseased sites the diversity and the microbial community leads to alterations in the host-microbe
richness of the community was significantly greater than in healthy crosstalk sufficient to mediate destructive inflammation and bone
sites [69,81]. The microbiota in the subgingival diseased pocket at loss [74] (Fig. 2). One microorganism potentially responsible for
the time of sampling may reflect both a proportional shift among the initiation of the dysbiosis phenomenon is the Gram-negative
genera secondary to initiation of disease and also a shift that fore- asaccharolytic bacterium P. gingivalis. P. gingivalis appears to thrive
shadows the progression of disease. at low frequency within the microbial community [69,80], but is
consistently associated with the onset of periodontal disease, pro-
gression, and treatment failure [76,105].
6. Cellularity and pathogenesis of periodontal disease As a minor member of the plaque biofilm but nonetheless a
keystone pathogen, the virulence factors of P. gingivalis appear to
The immunological response elicited by the microbial biofilm manipulate and depress the host response [74] rather than induce
is clearly complex. Innate immunity maintains tissue homeostasis inflammation and bone destruction [106]. Monocolonization of
and prevents periodontal tissue destruction. Neutropenia, agran- mice with P. gingivalis does not induce periodontal bone destruction
ulocytosis, neutrophil adhesion and chemotaxis deficiencies and after silk ligatures were placed on the teeth unless the commen-
diseases affecting degranulation of lysosomal contents are charac- sal microbiota was present [107]. P. gingivalis, therefore, appeared
terized by severe periodontitis [93]. Phagocytic antigen presenting necessary but not sufficient to induce bone destruction in a murine
cells such as dendritic cells (DCs) and Langerhans cells direct the model of periodontal disease [104].
phenotype of T helper (Th) cells. The cellular infiltrate in human gin- Indeed, P. gingivalis impairs host defenses in ways that facilitate
givitis is primarily composed of Th cells [94]. During an undefined the growth and development of the entire microbial community.
transition, the immune response in the gingiva switches from the The ability of P. gingivalis to modify the nutritional foundation for
recruitment and activation of neutrophils to clear pathogenic bac- the microbial community promotes significant shifts in the com-
teria to a chronic infiltrate of T, B cells and plasma cells [50,95,96]. position of the community. These features define P. gingivalis as
The chronic infiltrate of immune cells induces destruction of con- a keystone pathogen, a microorganism that can change the envi-
nective tissue, vascular proliferation and alveolar bone destruction ronment to alter proportions of other microorganisms within the
characteristic of periodontitis. ecological niche. The consequent disruption of the proportional
In murine models of periodontitis, CD4+ T cells are cen- relationship between strict symbionts and pathobionts triggers the
tral to the development of alveolar bone destruction [65,97,98]. destructive cascade leading to activation of inflammation and sub-
Although memory B cells and T cells release RANK-ligand to sequent bone destruction [108] (Fig. 2).
contribute to osteoclastic activation, Th cells release an ill- In general, the diversity and richness of the plaque micro-
defined set of cytokines immediately before initiation of alveolar biome associated with periodontal disease is greater than in health.
bone destruction [99]. Current research seeks to characterize P. Whereas studies of the oral microbiome must be interpreted in
gingivalis-specific CD4+ T cells locally in the marginal gingiva, define view of the technical sampling challenges, the increased diversity
the cellularity that predicts disease initiation and progression, and in disease reflects the etiology. In contrast to the gastrointestinal
determine the kinetics of clonal expansion and cytokine expression. microbiota, for example, in which a singular pathogen emerges
Using new immunological tools, epitope-specific CD4+ T cell phe- in a microbiota of less complexity, the microbiota in periodon-
notypes have been recognized that are specific for virulence factors tal disease shifts to include a higher proportion of pathobionts
of keystone pathogens such as P. gingivalis [100,101]. Also critical to and keystone pathogens. No singular pathogen emerges and the
the understanding of the pathogenesis of periodontal disease, the disease-associated microbiome is of greater complexity than in
epithelial innate immune cells such as DCs and Langerhans cells health (Fig. 10).
6.2. Virulence strategies of P. gingivalis only a small group of Treponema phylotypes show stronger asso-
ciation with diseased sites [119] fulfilling the characteristics of a
An asaccharolytic microorganism, P. gingivalis expresses a set of pathobiont rather than a keystone pathogen.
proteases that degrade proteins to use as an energy source and Interestingly, as bacterial biomass and clinical periodontal
also potentiate inflammation. The activation of inflammation is inflammation increase, the ecological succession from health to
part of a basic survival strategy increasing the protein-rich gin- disease is manifested as emergence of newly dominant community
gival crevicular fluid bathing the gingival sulcus while dampening members rather than appearance of novel species [120]. Conse-
killing mechanisms in phagocytic cells [109]. P. gingivalis produces quently, the emerging community may include members that can
Lys-and Arg-proteases (Kgp, RgpA and RgpB gingipains), which can subvert or evade the immune response (e.g., keystone pathogens),
activate complement C1q independently of antibody [110] and use thereby contributing to the stabilization of a disease-provoking
the C5 convertase-like enzymatic activity of RgpA and RgpB to biofilm dominated by pathobionts in individuals susceptible to
generate C5a anaphylotoxin [111]. Interfering with complement- periodontitis. Reflecting host genetic diversity and variability, sus-
toll-like receptor cross talk and phagocytosis facilitates survival of ceptibility may be related to several immunoregulatory factors. For
P. gingivalis whereas the products of protein hydrolysis provide a example, individuals of African descent show increased frequency
nutrient source in the complex antimicrobial environment of the and concurrent colonization with A. actinomycetemcomitans strain
gingival sulcus. JP2 in association with aggressive and localized forms of periodon-
P. gingivalis lipoprotein is another important virulence factor. titis [121]. Interestingly, A. actinomycetemcomitans not only has a
TLR2 recognition of the lipoprotein induces a weak cAMP response. tropism and infects a certain host genetic background [122] but
Activation of either CXCR4 or C5aR fails to induce cAMP. Strik- infection of the ecosystem generally follows a specific chronologic
ingly, however, cAMP production is synergistically increased when and site-specific pattern during the eruption of permanent incisors
P. gingivalis-stimulated TLR2 cooperates with activated C5aR and and first molars [123]. Hence, typically the incisor and molar teeth
CXCR4 in lipid rafts. Combined activation greatly increases cAMP- are selectively affected and A. actinomycetemcomitans is considered
dependent protein kinase (PKA) signaling, inactivating glycogen the causative agent of these aggressive forms of disease [124].
synthase kinase-3␤ and impairing inducible nitric oxide synthase
(iNOS)-dependent killing of bacteria in vitro and in vivo [112].
6.4. Challenges correlating shifts in the microbiota and disease
P. gingivalis also expresses an atypical lipopolysaccharide (LPS)
progression
(4-acyl monophosphate lipid A). In contrast to agonist E. coli
LPS, the atypical P. gingivalis LPS functions as a TLR4 antagonist
Despite very sophisticated efforts to analyze the periodontal
[113,114]. Using this immunological subterfuge, P. gingivalis fur-
microbiota at various stages of disease, knowing the microbial com-
ther reduces TLR-dependent iNOS production and iNOS-dependent
munity that is predictive of disease progression is still not possible
killing.
[125]. Indeed, the progression of periodontal disease is very diffi-
P. gingivalis employs other subterfuge mechanisms to inter-
cult to measure accurately [126] unless the disease has destroyed
nalize into phagocytic cells and yet be protected against killing
at least 1–2 mm of connective tissue and bone support along the
mechanisms. Binding of P gingivalis fimbriae (FimA) to phagocyte
root length [127]. Despite the sophisticated methods to define the
CD14-TLR2/TLR1 elicit an inside-out signal, which promotes inter-
composition of the microbial community, we still measure peri-
nalization of P. gingivalis. Normally committed to the uptake of
odontal disease crudely, with a metal pin known as the periodontal
apoptotic cells, the physiological role of CR3 is essentially hijacked
probe [127]. It will be extremely challenging, therefore, to predict
to internalize P. gingivalis [115,116]. Binding of CR3 activates ERK1
the microbial community members that elicit tissue destruction,
and ERK2 signaling in human monocytes, thereby inhibiting TLR2-
not because the specific species cannot be identified but because
induced IL-12 production and possibly Th1 differentiation [117].
of the lack of sensitivity of the method to measure progression of
After phagocytosis, P. gingivalis can sequester from phagolyso-
periodontal disease.
somes by diverting into the autophagic pathway.
6.3. Other pathogenic microorganisms 7. Caries microbiome and immunity
Emerging in aggressive juvenile forms of periodontitis, Dental caries is the single most common disease in childhood
Aggregatibacter actinomycetemcomitans (formerly Actinobacillus with a prevalence rate five times higher than the next most preva-
actinomycetemcomitans) and Treponema spp. are considered true lent disease, asthma. Over 50% of children in the United States ages
pathogens. A. actinomycetemcomitans is always below the lev- 5–9 years have at least one cavity or filling. This number increases
els of detection in healthy sites whereas the Treponema spp. to 78% by the time children reach adulthood (17 years of age). The
are also considered pathobionts. Recently, a murine commensal condition significantly contributes to the burden of pain, is associ-
microorganism similar to A. actinomycetemcomitans (NI1060, a ated with impaired development and marked decrease in quality
Gram-negative member of the Pasteurellaceae family) has been of life [128,129]. For decades since the 1950s, Streptococcus mutans
associated with severe alveolar bone loss in a murine silk lig- was held to be the etiological agent in dental caries. More recent
ature model of periodontitis [118]. The bone destruction was attempts to define the specific etiological agent(s) of dental caries
dependent on activation of the nucleotide-binding oligomeriza- have proven to be elusive. Caries etiology is more complex and
tion domain receptor 1 (NOD1). NOD1 is an innate immune multi-faceted than previously recognized.
receptor that mediates neutrophil recruitment by inducing the Caries active and caries-free individuals share approximately
secretion of chemokines from non-hematopoietic cells. Mice lack- 50% of the supragingival microbiome [130]. Only 10 genera were
ing NOD1 show decreased chemokine CXCL1 secretion from the expressed in high abundance including Streptococcus spp., Veil-
gingival epithelium in a ligature-induced model of periodontitis lonella spp and Actinomyces spp. S. mitis (25.5%) and S. sanguinis
and decreased bone destruction when compared to the wild-type (9.1%) were predominant. Streptococcus mutans (1.2%) was a com-
[118]. paratively minor constituent. When caries-active and caries-free
Several Treponema spp. appear consequent to P. gingivalis children were compared, significant differences in the microbiomes
appearance and grow to high abundance in diseased periodon- were attributed to low abundance phylotypes, Megasphera, Orib-
tal pockets. Despite a rich diversity of phylotypes in healthy sites, acterium, Moryella and Corynebacterium. The great majority of
represented phenotypes were similar in both caries-free and caries- Directly associated with caries formation, organic acids derived
active children but decreased in caries-active samples. Phylotypes from the hydrolysis of disaccharides like sucrose, are the final
overrepresented in caries-active subjects included S. sanguinis, S. metabolic products [136]. Environmental acidification of dental
mutans, S. sobrinus, S. mitis, S. intermedius, S. gordonii, S. parasan- plaque influences enzyme activities and also regulates transcrip-
guinis, S. constellatus, S. cristatus, S. oralis, S. equi, S. dentirousetti tion and translation (acid-induced adaptation through induction of
and S. peroris. Whereas S. mutans displayed greatest differential proteins/enzymes). An acidified environment causes a shift of the
abundance of the observed phylotypes, the spectrum of other microbial composition (acid-induced selection of acidogenic and
overrepresented bacteria suggests that a S. mutans etiology is aciduric microorganisms). This cycle will continue as long as the
ambiguous in dental caries. environmental acidification persists [137]. To fully explain the car-
iogenic potential of the microbial community at different stages
of the caries process, the metabolic activities relevant to environ-
7.1. Caries microbiota evolves with age and during disease mental acidification of the bacteria must be understood. Therefore
progression studies of the metabolome may be more relevant for explaining
caries activity than studies focusing exclusively on the microbiome.
In predentate and dentate infants and adult mothers, the pre- Collectively these data suggest that like the microbiome in peri-
dominant bacterial phyla in saliva common to all are Firmicutes, odontal disease, the plaque microbiota at the initiation of the
Proteobacteria, Actinobacteria, and Fusobacteria [131]. The diversity carious lesions is of greater complexity than in health to then fall
of genera in the adult was greater than in the infant. Streptococ- to a lower diversity in the established carious lesion. For decades,
cus spp. are the exception, predominating in infant saliva as 60% of S. mutans was viewed as a singular pathogen in caries. Recent stud-
clones while in the adult mother represent only 20%. The Veillonella, ies of the caries microbiome suggest a complex microbial etiology
Neisseria, Rothia, Haemophilus, Gemella, Granulicatella, Leptotrichia, with emergent pathobionts. A bacterial disease like dental caries,
and Fusobacterium are also the also predominant genera in the which appears to be caused by a complex microbiota rather than
infant, while Haemophilus, Neisseria, Veillonella, Fusobacterium, a single pathogen, may be associated with a microbiota of greater
Oribacterium, Rothia, Treponema, and Actinomyces are predominant complexity only at the initiation of disease. Unlike periodontal dis-
in adults [131]. In some Chinese populations, infants may show ease, established caries shows decreases in microbiome complexity
greater diversity in salivary phylotypes than adults by the age of 3 to probably due to acid environment, which limits the microbiota to
6 while maintaining proportions between different genera similar acidogenic and aciduric microorganisms.
to other reports [132].
The buccal and approximal surfaces of 4-year-old children har- 7.2. Immunity against caries
bor caries-associated taxa Granulicatella elegans, Veillonella spp. as
well as S. mutans and Bifidobacteriaceae spp. when analyzed with Individuals with low or non-detectable levels of Mutans strep-
PCR. Alternatively, caries-free children harbor Capnocytophaga gin- tococci early in life remain caries-free into adulthood as reported
givalis, Abiotrophia defectiva, Lachnospiraceae spp., Streptococcus in cross-sectional and longitudinal studies in Sweden [138]. Caries
sanguinis and Streptococcus cristatus [133]. susceptibility is inversely related to the output of salivary IgA in
Environmental acidification is hypothesized to be the main driv- children and young adults [139]. Indeed, salivary IgA antibody
ing force of the phenotypic and genotypic changes in the microbial titers against S. mutans are inversely related to levels of early oral
community during the caries process. In dentin affected by severe colonization and the colonized individual’s caries experience; the
caries common in children before the age of 16, acid-producing mechanistic immunogenic target of these relationships are the
Lactobacillus spp. primarily L. gasseri-L. johnsonii and L. casei-L. bacterial adhesins, glucosyltransferases (GTF), and glucan-binding
paracasei are dominant [134]. As caries progresses from initial dem- proteins (GBP) [140,141]. These antibody specificities are not unex-
ineralized lesions (white spots on the enamel) to deep cavitated pected, given the life-long presence of mutans streptococci in the
lesions, levels of these species increase significantly. In recent stud- oral biofilm. IgG antibody to mutans streptococci can be detected in
ies S. mutans is often observed at high levels in the white spots infant sera as a consequence of placental transfer and specific IgA is
but is also present in some healthy subjects in small numbers found in colostrum and breast milk, reflecting maternal experience
[134,135]. Surprisingly, S. mutans is only associated with caries with these microorganisms [142].
initiation (white spots) but not with caries progression. S. mutans Early in childhood, children begin to synthesize serum IgG
appears to have the characteristics of a keystone pathogen or of antibody to Mutans streptococcal antigens followed in time by
a pathobiont driven by a changing dietary environment. In some production of IgA. Serum IgG antibody levels increase during child-
patients, Lactobacillus spp. and S. mutans are found at low levels or hood and remain detectable throughout life. In young adults, anti-S.
below detection suggesting that the initiation and progression of mutans IgG titers are inversely related to disease levels [143].
carious lesions cannot be attributed to S. mutans [134,135]. In older adults, serum IgG antibody to cariogenic streptococci is
In white spots indicating early, demineralized enamel, other directly related to cumulative dental caries experience, whereas
potential acid producers are observed at high levels including IgA levels were inversely related [144]. This reciprocal relationship
strains of Selenomonas, Neisseria, and S. mitis. Propionibacterium spp. between IgA and IgG responses throughout life indicates that the
are associated with caries progression but are not found at high lev- initial adaptive immune responses to mutans streptococcal anti-
els. Attempts to discriminate the microbiome of caries-active and gens may influence the time and rate at which these streptococci
caries-free individuals at the specific ecological niche have proven join the biofilms of the primary dentition.
technically difficult. The biomass available for analysis is limited The level and specificity of the immune response may also affect
at specific sites such as enamel pits and fissures or interproximal the ability of commensal Mutans streptococci to colonize newly
areas where the caries risk is the greatest (Fig. 8). Overall an initially erupting primary and permanent teeth. For example, salivary IgAs
diverse community in caries-free sites and in white spots appears against Mutans streptococci in caries-active children react to dif-
to shift to progressive loss of families in caries-active sites. Species ferent epitopes when compared to anti-S. mutans salivary IgA in
minimized in caries-active sites include Lachnospiraceae spp., the S. caries-free individuals [145]. Secretory IgA antibody from parotid
mitis-S. pneumoniae-S. infantis group, Corynebacterium matruchotii, gland or serum IgG derived from the gingival crevicular fluid may
S. gordonii, S. cristatus, Capnocytophaga gingivalis, Eubacterium influence the accumulation of a cariogenic microbiota at various
IR009, and Campylobacter rectus [134]. stages of infection [146]. Caries and the associated microflora likely
increase the antigenic load and stimulate the immune responses. Acknowledgments
Yet the antigenic load and history disease in adulthood may tell
us little about the impact of the immune response on the estab- Research in the investigators’ labs is supported by NIH/NIDCR 1
lishment of cariogenic oral microorganisms and the clinical course R21 DE022858 (MC) and 1 R01 DE021206 (MCH).
of disease. In the presence of a seemingly protective immune
response, environmental challenges like an increase in dietary
sugar may cause an increase in production in bacterial acids and
mark progression of caries (reviewed in [147]. After eruption of pri- References
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Immunology Letters 162 (2014) 22–38

Contents lists available at ScienceDirect

The oral microbiome and the immunobiology of periodontal disease

(http://www.homd.org/). HOMD stores 34,753 ﬁltered cloned

6.3. Other pathogenic microorganisms 7. Caries microbiome and immunity

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