By: Sarah Kahil

Course: ENDO511

20/12/2015

ENDODONTIC MICROBIOLOGY
ROLE OF BACTERIA IN PULP AND PA PATHOSIS
Kakahashi 65 demonstrated presence of bacteria is necessary to
produce pulpal necrosis and periapical inflammation.
Moller 81 demonstrated non-infected necrotic pulp tissue did not
produce inflammatory reactions in periapical tissues.
TERMINOLOGY
- Colonization: the establishment of bacteria or other
microorganism in a living host.
- Infection: damage the host and produce clinical signs and
symptoms.
- Pathogenicity: the capacity of organisms to produce disease
within a particular host.
- Virulence: the degree of pathogenicity in a host under defined
circumstance.
- Planktonic cells: free floating bacterial cells
- Sessile cells: bacterial cells present in groups of coaggregates
(cells with distinct morphologies) OR aggregates (cells with the
same morphology)
- Biofilm: sessile multicellular microbial community characterized
by cells that are firmly attached to a surface and enmeshed in a
self-produced matrix of extracellular polymeric substance (EPS),
usually polysaccharide.
- Strict anaerobes: function at low oxidation-reduction potential
and grow only in the absence of oxygen, but they vary in their
sensitivity to oxygen.
- Obligate anaerobic bacteria: they can grow in the presence of
oxygen, but they derive most of their energy from anaerobic
energy pathways.

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By: Sarah Kahil

Course: ENDO511

20/12/2015

- Facultative anaerobic bacteria: can grow in the presence or

absence of oxygen
- Obligate aerobic bacteria: require oxygen for growth.

Spread of infection depends on:

- Nr and virulence of bacteria
- Host defense
- Associated anatomical structures
ROUTES OF BACTERIA TO THE PULP SYSTEM
-

Caries
Trauma and restoration leakage
Anachoreasis
Periodontal disease

Dental Caries:
A. Facultative gram +ve bacteria
- Propionibacterium
- Eubacterium, arachnia
- Lactobacilli, bifidobavcterium
- Actinomyces
B. Some of gram ve
- Bacteroides
The most common pathway to the root canal system for microbes.
When the tooth is intact, enamel and dentin protect it against invasion
of the pulp space. As caries approaches the pulp, reparative dentin is
laid down to avert exposure, but this rarely can prevent microbial entry
without caries excavation.
DENTINAL TUBULES

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By: Sarah Kahil

Course: ENDO511

20/12/2015

1 to 4 microns in diameter and bacteria are less than 1 micron in

diameter
Bacterial movement is restricted by:
-

Outflow of dentinal fluid

Odontoblastic processes
Mineralized crystals
Macromolecules, including immunoglobulins in the tubules

PERIODONTAL DISEASE
-

Accessory canal
Furcation canal
Lateral canal
Apical foramen
Exposed dentinal tubule

** Anaerobic bacteria gram ve rod, spirochete

TRAUMA
Pulp exposure due to trauma give access to oral bacteria, this will
cause bacterial invasion to the pulp inflammation pulp necrosis
Healthy exposed vital pulp, the penetration of tissues by bacteria is
relatively slow < or equal to 2 mm/week
ANACHORESIS
Blood borne bacteria is preferentially localized in areas of inflammation
VIRULENCE FACTORS
- Lipopolysaccharides (LPSs): are present on the surface of
Gram ve bacteria have multiple biologic effects that induce
periapical pathosis.
- Activate the complement cascade (classic and alternative
pathways). It is called Endotoxins when released from the cell
wall.

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By: Sarah Kahil

Course: ENDO511

20/12/2015

- Extracellular vesicles: produced by gram ve bacteria in form

of free blebs and outer membrane fragments, they have the same
antigenic determinants of the parent bacteria (protect the
bacteria by neutralizing the specific antibodies) may be involved
in hemoagglutination, hemolysis, bacterial adhesion, and
proteolytic activities.
- Enzymes:
neutralize
immunoglobulins
and
complement
components, may help in spread of infection in cellulitis ( ex:
protease, collagenase and metalloprotease).
- Short-chain fatty acids: produced by anaerobic bacteria, affect
neutrophil chemotaxis, degranulation, phagocytosis, and other
intracellular changes. Butyric acid stimulate production of
interleukin-1 which is associated with bone resorption and
periradicular pathosis Ex: propionic, butyric, and isobutyric acids)
- Polyamines: they are involved in the regulation of cell growth,
regeneration of tissues, and modulation of inflammation. They are
higher in necrotic pulps associated with spontaneous pain or pain
with percussion and cases with sinus tract. Ex: putrescine,
cadaverine, spermidine, and spermine)

Bacterial Virulence Factors

Virulence Factor
Fimbriae, pili, fibrillae

Mechanism of Action
Bacterial attachment, prevention
of bacterial phagocytosis
Capsule, exopolysaccharide, Bacterial attachment, prevention
glycocalyx
of
bacterial
phagocytosis,
protection from complement and
immune system
Peptidoglycan,
muramyl Immunodilation,
induction
of
peptides
inflammatory mediators
Endotoxin
Activation
of
inflammatory
response, activation of cytokine
production, induction of bone
resorption

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By: Sarah Kahil

Course: ENDO511

Proteolytic
enzymes:
collagenase,
gelatinase,
hyaluronidase,
fibrolysin,
immunoglobulin
proteases.
H2S
and
volatile
sulfur
compunds
Inorganic acids: butyric acid,
propionic acid
Superoxide dismutase

20/12/2015

Breakdown of host connective

tissue; host tissue invasion

Host cell toxicity

Breakdown of oxygen products,
protecting anaerobes

ENDODONTIC BACTERIAL ECOLOGY

- Bacterial composition over time: facultative to obligate anaerobes
(oxygen, nutritional demands).
- Gram +ve to gram ve organisms
- Nutritional demands of bacteria change within root canal over
time.
- Rate of bacterial invasion depends on numbers and virulence of
bacteria, nutrient availability, and atmospheric conditions.
POLYMICROBIAL
- The number of microorganisms detected in endodontic infections
increased to a range of 3 to 12 organisms per infected root canal
associated with an apical lesion.
- The number of colony forming units (CFU) is usually 10 2 to 1010
- A positive correlation exists between the number of bacteria in an
infected root canal and the size or periradicular radiolucency
Intact teeth with necrotic pulp: strictly anaerobes more than 90% of
the bacteria
The apical 5 mm of various carious exposed teeth: 67% of the bacteria
were strictly anaerobes.

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By: Sarah Kahil

Course: ENDO511

20/12/2015

FUNGI
- Fungi are eukaryotic microorganisms that may colonize the oral
cavity, especially candida species, but they have been only
occasionally detected in primary Intraradicular infections.
- Reported C. albicans in 21% of samples from primarily infected
canals.
VIRUSES
- Because viruses require viable host cells to infect and replicate
themselves, they cannot thrive in the root canal with necrotic
pulp.
- Viruses have been reported to occur in the root canal only in
noninflamed vital pulps of patients infected with the human
immunodeficiency virus.
- Human cytomegalovirus (HCMV) and Epstein-Barr virus (EBV)
have been detected in apical periodontitis lesions.
ENDODONTIC INFECTION
Intraradicular

Extraradicular

- Primary
- Secondary
- Persistent
PRIMARY ENDODONTIC INFECTIONS
- Primary infections are caused by microorganisms that initially
invade and colonize the necrotic tissue.
- Primary infections are characterized by a mixed clostridium
composed of 10-30 species per canal.
- The number of bacterial cells in an infected canals varies from
103-108 cells.

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By: Sarah Kahil

Course: ENDO511

20/12/2015

- Recently findings from molecular studies have also suggested

that some anaerobic species commonly found in primary
infection.
Anaerobic bacteria:
Fusibacterium 48%
Prevotella, porphyromona s, Tanerella, Dialister, Camphylobactor,
Treponema, Peptostreptococcus 40% Actinomyces, Eubacterium,
Filifactor, Psudoramibactor
BLACK PIGMENTED BACTERIA
Prevotella:
1.
2.
3.
4.

P.
P.
P.
P.

intermedia
nigrescence
tannerae
multisaccharivorax

Porphyromonas
1. P. endodontalis
2. P. gingivalis
They seem to play an important role in the etiology of both acute and
chronic apical periodontitis, cases with purulent discharge and 51% of
symptomatic cases
SECONDARY ENDODONTIC INFECTION
Microorganisms not the primary cause of infection, but have been
introduced into the root canal during or after root canal treatment
There is increased risk of adverse outcome of the endodontic
treatment.
- Create both excellent apical and coronal seal
- Prevent bacterial nutrient regain in to the canal

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By: Sarah Kahil

Course: ENDO511

20/12/2015

MICROBIAL IN ROOT FILLED TEETH

Unlike primary infection, a more restricted group of microbial species
has been found in secondary infection.
The prevalence of Enterococcus feacalis has been finding in all
studies that investigated flora in root-filled teeth 30-90% Facultative
anaerobie, Gram positive coccus. (P.aeruginosa, Staphylococcus)
Fungi in secondary infection:
The occurrence of yeasts were taken from samples that not responding
in favorably to conventional treatment 72% of cases). Candida albicans
was the most common species
PERSISTENT INTRARADICULAR INFECTION
Microorganisms resist antimicrobial procedures and can resist periods
of nutrients deprivation in a prepared root canal. They are fewer
species than in primary or secondary infections. Mainly gram positive
facultative or anaerobic infection, Fungi also can be found.

EXTRARADICULAR INFECTION
Microbial invasion and proliferation in inflamed periradicular tissue. It
can be dependent (sequel of Intraradicular infection acute apical
abscess) so can be successful (actinomycosis) where surgery is must.
BIOFILMS
Defined as a sessile multicellular microbial community characterized
by cells that are firmly attached to a surface and enmeshed in a selfproduced matrix of extracellular polymeric substance (EPS) usually
polysaccharide

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By: Sarah Kahil

Course: ENDO511

20/12/2015

BENEFITS:
-

A broader habitat range for growth

A more efficient metabolism
Increased resistance to stress and antimicrobial agent
Enhanced virulence

INFECTION CONTROL
Standard of care for infection control
Endodontic treatment or extraction

Debridement of the root canal system

Intracanal medication
Drainage
Antibiotics
Bacterial sampling for resistant cases

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