Periodontology 2000, Vol. 67, 2015, 58–86 Printed in Singapore. All rights reserved

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

PERIODONTOLOGY 2000

Periodontal microbiology in Latin America A D O L F O C O N T R E R A S , S A N D R A M. M O R E N O , A D R I A N A J A R A M I L L O , M E L I S S A P E L A E Z , A N D R E S D U Q U E , J A V I E R E. B O T E R O & J Ø R G E N S L O T S

Periodontal diseases affect a large proportion of the world’s population and are considered an important health issue in developed and developing countries (150). The subgingival microbiota involved in the onset and progression of periodontal disease has been a major research topic for more than 40 years (13, 48, 177, 181, 182, 190, 199). The latest research based upon sequencing of the 16S rRNA gene has identified 800–1,000 bacterial and Archaea oral species, representing 19,000 phylotypes, and many of the organisms are unculturable (96, 112, 149, 152, 207). In spite of the sizeable microbial diversity, only about 50 bacterial species are closely related to periodontal breakdown (35, 190). Evidence for bacterial specificity in periodontitis comes from culture studies on microbial occurrence in health and disease and on virulence factors in in vitro and in vivo study models. However, a major portion of the periodontal microbiota remains incompletely characterized, and the virulence and the immunobiology of the newly identified bacteria are essentially unknown. Bacteria that are present in elevated proportions in disease-active periodontitis are designated major pathogens or ‘red complex’ bacteria; they include Aggregatibacter actinomycetemcomitans (formerly Actinobacillus actinomycetemcomitans), Porphyromonas gingivalis, Tannerella forsythia and Treponema denticola (190). Other species may also contribute to periodontal destruction, such as Prevotella intermedia, Prevotella nigrescens, Campylobacter rectus, Campylobacter gracilis, Parvimonas micra, Eubacterium species, Dialister pneumosintes and Dialister invisus. A diverse group of gram-negative enteric rods, including Pseudomonas and Acinetobacter, beta-hemolytic Streptococcus, Staphylococcus and Candida can also inhabit periodontitis lesions (15, 27, 113, 177, 178), and human viruses have been linked to severe types of periodontal disease (40, 173) and peri-implantitis

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(100). Alpha-hemolytic streptococci and actinomyces species, bacteria possessing little or no periodontopathic potential, predominate in periodontal health and after successful periodontal therapy (35, 122, 182). The periodontopathic significance is not known for the newly described bacteria Filifactor alocis, Pseudoramibacter alactolyticus, Selenomonas noxia, TM7 species, Deferribacter species, Solobacterium moorei, Bacteriodetes species OT 272, Desulfobulbus species OT 041, Shuttleworthia satelles, Granulicatella adiacens, Mogibacterium timidum, Megasphaera species, Catonella species, Synergistes species cluster II, Brevundimonas diminuta and Sphaerocytophaga species (111). The maintenance of a stable periodontium depends on obtaining a balance between ‘beneficial’ and pathogenic bacterial species and between protective and destructive host immune responses (13, 54). Microbial dysbiosis refers to an alteration of this equilibrium and represents an important concept in the understanding of the etiopathogenesis of periodontal disease. A herpesviral infection of the periodontium can upset local immunity and give rise to upgrowth of bacterial pathogens and subsequently destructive periodontal disease (172). Members of bacterial species/phylotypes can exhibit considerable genetic variations, and whole genomes of multiple strains of a given species may only share about two-thirds of the genetic material (60, 162, 192). Genetic variability may explain why some phylogenetic lineages of bacterial species are closely associated with disease, whereas other phylotypes of the same species can persist in a host without causing notable disease (140, 166). A bacterial species, according to this concept, can be view as a group of heterogeneous, but related, microbial clones that demonstrate varying degrees of pathogenic potential (49, 58, 92, 99, 110, 187). A recent study proposed that genetic variations within

Periodontal microbiology in Latin America

the oral microbiome can influence the outcome of periodontal treatment (165). A major challenge in studying periodontal microbiology is the complexity that exists among individuals in terms of socio-economic status, oral hygiene practices and other environmental determinants of periodontopathogenicity (78, 157). Difficulties in periodontal research even extend into such basic concepts as definition and classification of periodontal diseases (10, 175). Nonetheless, with recent advances in molecular diagnostics, it is hoped that the more complete picture of the periodontal microbiota can lead to a better understanding of the initiation and progression of periodontitis and to more cost-effective approaches to therapy. This review focuses on studies from the past 20 years that have addressed the microbial composition of periodontitis in Latin America. We performed a systematic search of periodontal microbiological studies from Central and South America, using the following databases: MEDLINE, LILACS (Latin America and Caribbean Literature in Health Science) and BBO (Brazilian Library of Dentistry). The search keywords, in English, Portuguese or Spanish, were ‘periodontal microbiology’, ‘chronic periodontal disease microbiology’, ‘aggressive periodontitis microbiology’, ‘gingivitis microbiology’ and ‘oral health microbiology’. Other relevant publications were also included when appropriate. All 22 countries in Central and South America were incorporated in the literature search.

Methodological issues The prevalence of periodontal disease and specific periodontal microbes in Latin America can be difficult to assess due to variability in study design, uncertain clinical diagnoses and vague criteria for case selection (62, 145, 148). However, despite these obstacles, it seems clear that a high proportion of individuals in Latin America and in other developing parts of the world exhibit particularly severe types of periodontal disease (150). The occurrence of severe periodontal disease is related to environmental factors, such as oral hygiene habits, socio-economic status and lack of access to proper therapy, and to biological determinants, including genetic susceptibility, microbial composition and immunocompromising diseases/conditions. A wide range of methodologies have been used in the search for periodontal pathogens. Microbiological methods in current use are microbial culture, ELISA,

immunofluorescence, DNA–DNA hybridization, endpoint PCR, real-time PCR and next-generation sequencing techniques (147). The new molecularbased diagnostic methods are capable of detecting minute amounts of specific microorganisms. However, in the context of periodontal disease, only pathogens that exceed a certain critical threshold may be relevant for disease initiation and progression. This realization complicates the interpretation of purely qualitative data obtained by exquisitely sensitive microbiological techniques.

Microbial sampling Securing a representative sample of the disease-associated microbiota can be challenging, especially when sampling deep periodontal pockets (30, 105). The need for a large representative sample is particularly important when using microbiological techniques with high detection thresholds, such as culture (176) and DNA–DNA checkerboard analysis (183, 184), and is relevant to a lesser degree when using technologies with low detection thresholds, such as PCR (5, 30, 87). The validity of a microbiological examination depends also on the number of periodontal sites that are sampled and the method of sampling (208). Periodontal pocket sampling by paper points seems to yield more pathogens than sampling by curettes (156). Saliva samples are easier to collect than subgingival samples (196), and the levels of periodontopathic microbes in saliva can potentially be used to screen for the presence of periodontitis (163, 179). However, the salivary level of an organism may not correlate well with its subgingival level in individual patients and thus may not always provide an accurate assessment of the periodontal disease status.

Microbial identification methods Culture-based identification has a long tradition in periodontal microbiology (171, 177). In contrast to the other techniques described below, the recovery by culture depends on the composition of the sample transport medium and the length of the transport time. The culture methods have gradually been enhanced by the introduction of more proficient anaerobic handling and incubation procedures and by improvements of nonselective and selective culture media. However, as culture-based techniques depend heavily on the skills of the laboratory personnel and on equipment-related factors, as well as on the methods employed for microbial identification,

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sies from cytomegalovirus-positive individuals with periodontitis than in biopsies from cytomegalovirusnegative patients with periodontitis. The ability of cytomegalovirus to upregulate the expression of mRNA for collagens and metalloproteinases may contribute to the development of periodontitis. Other pathways by which herpesviruses may cause periodontitis include direct cytopathic effects on fibroblasts, keratinocytes and other types of cells (19, 20, 40, 83) and synergistic pathogenetic interactions with periodontopathic bacteria (22, 172, 179). In Brazil, Watanabe et al. (203) detected Epstein– Barr virus-1 in 57% of sites with aggressive periodontitis and in 30% of sites with gingivitis; the relative risk for periodontitis was 3.05 with a confidence interval of 1.43–6.47. Cytomegalovirus was found in 6% of the study individuals (203). Imbronito et al. (98) identified Epstein–Barr virus-1 in 45% of chronic periodontitis samples, 38% of salivary samples and 25% of peripheral blood samples. Cytomegalovirus was detected in 82% of the periodontitis and blood samples and in 75% of the saliva samples (98). Grande et al. (82), in a study of HIV-infected subjects, found cytomegalovirus in 82% of periodontitis sites of HIVpositive and in 80% of periodontitis sites of HIV-negative patients, and Epstein–Barr virus-1 in 72% of periodontitis sites of HIV-positive and in 48% of periodontitis sites of HIV-negative patients. In another study of HIV, Grande et al. (83) detected cytomegalovirus and Epstein–Barr virus-1 in, respectively, 74% and 70% of periodontitis samples, in 77% and 81% of salivary samples, and in 74% and 22% of peripheral blood samples. Herpes simplex-1 virus occurred with a frequency of 4% in periodontitis samples and 15% in salivary samples, and was not detected in blood samples (83). Nishiyama et al. (143) also found a low occurrence (3%) of herpes simplex-1 virus in periodontitis lesions. Casarin et al. (29) studied the relationship between herpesviruses and periodontal status in patients with type 2 diabetes and found Epstein–Barr virus in 81% of shallow periodontal sites of patients with poor glycemic control and in 43% of shallow periodontal sites of patients with good glycemic control (P = 0.05). Cytomegalovirus occurred in 33–43% of shallow periodontal sites, with no preference for poorly controlled diabetes (29). The elevated prevalence of herpesviruses in periodontal sites of patients with type 2 diabetes may partly explain the elevated risk of these patients for developing periodontitis. Human viruses other than herpesviruses can also reside in the periodontium. Escalona et al. (63) in Venezuela studied the presence of human papilloma-

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virus in periodontal pocket samples of HIV-infected patients. Papillomavirus was detected in 46% of HIVpositive patients receiving anti-retroviral treatment, but was not found in HIV-seronegative patients (63). Horewicz et al. (95) did not detect the oncogenic papillomavirus type 16 in samples from chronic periodontitis, gingivitis or healthy periodontium. Lins et al. (116) found that individuals orally infected with the human T-lymphotropic virus type I were more affected by periodontitis than were noninfected controls.

The future of periodontal microbiology in Latin America A healthy periodontium is important for overall oral health, but the increasing evidence that periodontitis also can have systemic consequences raises treatment of periodontal disease to a new level of importance (38, 102, 154, 197). Periodontal disease has a global distribution, but is particularly prevalent and severe in low-income individuals. Many periodontitis patients of Central and South America do not receive adequate periodontal therapy because of economic and social constrains and a scarcity of affordable dental services. There is a need to find safe and effective methods to control periodontal infections in Latin American populations with limited access to professional dental care. Knowledge of the periodontal microbiota is critical for implementing a successful periodontal therapy. Periodontal therapy aims to control periodontopathic microorganisms by means of mechanical pocket debridement, periodontal pocket irrigation with potent antiseptics, treatment of advanced disease with systemic antibiotics and attention to proper selfcare. The worldwide increase in antibiotic-resistant bacteria and the high costs of new, effective antibiotics have created interest in the use of inexpensive antiseptics to combat periodontal infections. Antiseptics are broad-spectrum microbicidal agents that are applied topically onto living tissue to prevent or treat clinical infections caused by bacteria, yeasts and viruses (174, 175). Unlike antibiotics, antiseptics destroy periodontal bacteria and viruses in a nondiscriminative manner and can cover the entire spectrum of traditional periodontal pathogens, gramnegative enteric rods and superinfecting organisms (190, 191). Low-cost periodontal therapy, based predominantly on antiseptic agents, may help to meet the unmet treatment needs of large impoverished populations in Latin America (57, 174, 175).

Periodontal microbiology in Latin America

Table 1. Studies on the subgingival microbiota in Brazil Study type and Author/Year

Findings

Prevalence of Aggregatibacter actinomycetemcomitans Aggressive periodontitis Avila-Campos et al. (1995) (7)

77% with predominance of biotype X in 30 subjects with periodontitis

Tinoco et al. (1997) (194)

80% prevalence in adolescents, 39.5% in their family members, 35.3% in the adolescent’s parents and 43.9% in their siblings

Chronic periodontitis Avila-Campos et al. (2002) (9)

Cultures showed a significant association between A. actinomycetemcomitans and periodontitis, along with Tannerella forsythia and Prevotella intermedia

Malheiros et al. (2004) (125)

18% prevalence with a predominance of biotype II

Jardim et al. (2006) (104)

68% prevalence in chronic periodontitis

Leukotoxic Aggregatibacter actinomycetemcomitans strains Guazeli-Amin et al. (2000) (84)

Both leukotoxic and nonleukotoxic strains of A. actinomycetemcomitans can be isolated from localized juvenile periodontitis and from patients with AIDS/necrotizing ulcerative periodontitis, but A. actinomycetemcomitans with high leukotoxic activity is more frequent in localized juvenile periodontitis than in patients with AIDS/necrotizing ulcerative periodontitis

Rosalem-Junior et al. (2006) (161)

Deletion of a 530-bp sequence in the leukotoxin gene was observed in 16 (57.1%) of the 28 patients with generalized advanced periodontitis who were positive for A. actinomycetemcomitans. The deletion was not detected in individuals with periodontal health

Cortelli et al. (2005) (42)

A higher prevalence of leukotoxic strains of A. actinomycetemcomitans was detected in Brazilian subjects with aggressive periodontitis and with the deepest pockets (>6 mm)

Cortelli et al. (2003) (45)

There was a significant correlation between highly leukotoxic A. actinomycetemcomitans and aggressive periodontitis (v2 = 22.06). However, a significant correlation was not detected when analyzing separate periodontal variables as pocket depth (v2 = 0.73), plaque index (v2 = 0.35) and bleeding index (v2 = 0.09)

Gaetti-Jardim et al. (2008) (74)

Only one of 50 samples from Brazilian patients with periodontitis harbored highly leukotoxic A. actinomycetemcomitans. Biotype II was the most prevalent, and no correlation between biotypes and leukotoxic activity was observed

Vieira et al. (2009) (202)

In Indians from the Umutina Reservation, Mato Grosso, all A. actinomycetemcomitans strains were grouped as non-JP2 clones based on the absence of a 530-bp deletion in the leukotoxin promoter gene

Studies on the red complex bacteria: Porphyromonas gingivalis, T. forsythia and Treponema denticola Gaetti-Jardim et al. (1998) (75)

A higher frequency of red complex bacteria was found in patients with periodontitis. Black-pigmented bacteria and Fusobacterium spp. were common. An association was found between T. forsythia and P. gingivalis

Rodrigues et al. (1999) (158)

156 isolates of black-pigmented bacteria were recovered from 30 Brazilian subjects. The most predominant bacteria were P. intermedia/Prevotella nigrescens (93.9%), P. gingivalis (12.1%) and Prevotella spp. (6.1%)

Shibli et al. (2008) (167)

The microbiota of peri-implant disease revealed higher total colony counts than in peri-implant healthy sites. Porphyromonas gingivalis, T. denticola and T. forsythia were present in supra- and submucosal sites of peri-implantitis

Fernandes et al. (2010) (71)

Porphyromonas gingivalis and T. forsythia were more prevalent on the tongue than on the cheek. Diverse niches of the oral cavity can harbor periodontopathic bacteria

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Table 1. (Continued) Study type and Author/Year

Findings

Ide et al. (2000) (97)

66 Xingu Indians with periodontitis harbored P. gingivalis (53%), Campylobacter rectus (31%), T. forsythia (25%), P. intermedia (22%), A. actinomycetemcomitans (17%), T. denticola (17%) and Eikenella corrodens (14%). Forty-nine Xingu Indians with gingivitis were positive for P. gingivalis (20%), A. actinomycetemcomitans (10%) and E. corrodens (2%)

Missailidis et al. (2004) (136)

Porphyromonas gingivalis occurred in 89.4% of patients with periodontal attachment loss, in 30% of patients with gingivitis and in 8.0% of healthy subjects. The most prevalent P. gingivalis genotypes in patients with periodontitis were fimAII and fimAIb. Genotype V was not detected in any of the samples and genotype IV was the most common in patients with gingivitis

Teixeira et al. (2009) (189)

An association was found between P. gingivalis fimAIV and disease severity in smokers with chronic periodontitis

Trevilatto et al. (2002) (195)

Actinobacillus actinomycetemcomitans, P. gingivalis, T. forsythia and T. denticola were detected in a family with aggressive periodontitis

Heller et al. (2012) (93)

Actinomyces gerensceriae, Actinomyces israelii, Eubacterium nodatum and Propionibacterium acnes showed significantly higher counts in generalized aggressive periodontitis, whereas Capnocytophaga ochracea, Fusobacterium periodonticum, Staphylococcus aureus and Veillonella parvula predominated in patients with chronic periodontitis (adjusted P < 0.001)

da Silva-Boghossian et al. (2011) (52) Putative periodontal pathogens and nonoral bacteria, alone, or in association with classical periodontopathogens, were strongly associated with periodontitis Bonifacio et al. (2011) (16)

A high frequency of periodontal pathogens was associated with the severity of periodontal disease (P. gingivalis, T. forsythia, A. actinomycetemcomitans, C. rectus and P. intermedia)

Periodontitis and systemic diseases Human immunodeficiency virus Goncalves et al. (2004) (80)

The subgingival microbiota of HIV-positive patients with chronic periodontitis included a high prevalence of the classical periodontal pathogens present in non-HIV-infected individuals

Ramos et al. (2012) (155)

Tannerella forsythia was a prevalent periodontal species in HIV-positive patients. E. corrodens, Dialister pneumosintes, Streptococcus intermedius and C. rectus were also recovered from periodontal lesions of HIV-positive patients

Diabetes mellitus da Cruz et al. (2008) (51)

Diabetic and nondiabetic patients did not differ significantly in microbial composition (P. gingivalis, T. forsythia and A. actinomycetemcomitans)

Cardiovascular disease Marcelino et al. (2010) (126)

A significant association was found between the presence of P. gingivalis and atheromas

Romito et al. (2004) (160)

In patients with heart transplants, subgingival samples yielded a prevalence of 93% for P. intermedia, 66% for Fusobacterium nucleatum , 66% for Parvimonas micra and 30% for C. rectus

Studies on other bacteria Gebara et al. (2004) (77)

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Helicobacter pylori was found in the saliva of three (10%) patients, in the supragingival plaque in six (20%) patients and in the subgingival plaque in eight (26.6%) patients. However, the organism was not recovered from the dorsum of the tongue of any patient. The presence of H. pylori was similar in patients with gingivitis and chronic periodontitis

Periodontal microbiology in Latin America

Table 1. (Continued) Study type and Author/Year

Findings

Silva et al. (2010) (168)

Helicobacter pylori was detected in supragingival plaque, but not in subgingival plaque, of individuals with periodontal disease and upper gastric diseases

Oliveira et al. (1998) (146)

Fusobacterium bacteriocins were found in periodontally diseased and healthy subjects

Loberto et al. (2004) (117)

Staphylococcus spp. were recovered from subgingival sites of patients with chronic periodontitis

Haffajee et al. (2004) (86)

Actinomyces naeslundii had a prevalence of 8.4% of genospecies 1 and 7.2% of genospecies 2

Goncalves et al. (2007) (81)

Periodontal patients yielded Enterobacter cloacae (43.75%), Serratia marcescens (31.25%), Klebsiella pneumoniae (6.25%), Enterobacter aerogenes (6.25%), Pantoea agglomerans (6.25%) and Citrobacter freundii (6.25%)

Ferraro et al. (2007) (72)

Dialister pneumosintes was positively associated with periodontitis

Faveri et al. (2008) (67)

Selenomonas spp. and Streptococcus spp. were associated with generalized aggressive periodontitis

Faveri et al. (2011) (66)

Peri-implantitis sites showed a significantly higher prevalence of Archaea than did peri-implant healthy sites and natural teeth

Matarazzo et al. (2011) (132)

The levels and proportions of Archaea were higher in generalized aggressive periodontitis than in periodontal health. The predominant species was Methanobrevibacter oralis

Souto et al. (2006) (185)

Predominant species in 600 subgingival samples from 14 subjects with chronic periodontitis included Corynebacterium diphtheriae, Enterococcus faecalis, S. aureus and Escherichia coli

Souto et al. (2008) (186)

Enterococcus faecalis was detected significantly more often in saliva (40.5%) and in subgingival samples (47.8%) of patients with periodontitis compared with controls (14.6% and 17.1%, respectively)

Bacterial resistance studies Avila-Campos et al. (1989) (8)

The minimal inhibitory concentration of mercuric chloride was 4 lg/ml

Feres et al. (2002) (70)

Metronidazole-resistant microorganisms: A. naeslundii 1, Streptococcus constellatus, A. naeslundii 2, Streptococcus mitis, Streptococcus oralis, Actinomyces odontolyticus and Streptococcus sanguis Amoxicillin-resistant microorganisms: S. constellatus, P. nigrescens, Eubacterium saburreum, A. naeslundii 1, Streptococcus oralis, Prevotella melaninogenica and P. intermedia

Rodrigues et al. (2004) (159)

Tetracycline-resistant microorganisms: Streptococcus spp., V. parvula, P. micra, P. intermedia, Gemella morbillorum and A. actinomycetemcomitans

Clinical trials Matarazzo et al. (2008) (131)

Evaluated the clinical and microbiological effects of scaling and root planing alone or in combination with metronidazole (N = 15) or with metronidazole + amoxicillin (N = 14) in smokers with chronic periodontitis. The scaling and root planing + metronidazole + amoxicillin therapy showed significant reductions in the mean counts and proportions of T. forsythia, P. gingivalis and T. denticola, and the considerable increase in proportions of non-periodontopathic species

Feres et al. (2009) (69)

The clinical and microbiological effects were assessed of scaling and root planing, alone, or combined with mechanical (professional plaque control) or chemical (chlorhexidine rinsing) treatment of supragingival plaque in 60 patients with chronic periodontitis. Overall, the chlorhexidine rinse treatment showed a significant reduction in the proportions of red and orange bacterial complexes

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Table 1. (Continued) Study type and Author/Year

Findings

Haas et al. (2012) (85)

Azithromycin was ineffective in lowering the subgingival levels of important putative periodontal pathogens in young subjects with aggressive periodontitis compared with placebo

Novaes et al. (2012) (144)

Antimicrobial photodynamic therapy associated with scaling and root planing may be beneficial for the nonsurgical treatment of aggressive periodontitis

nance of biotype II (125). Leukotoxic strains of A. actinomycetemcomitans (JP2 clone, serotype b) were a common finding in aggressive periodontitis in South America, with a particularly high prevalence in Brazil (84, 161). Cortelli et al. (42) found a higher occurrence of A. actinomycetemcomitans and of highly leukotoxic strains in Brazil than in other South American countries, and linked highly leukotoxic strains to a greater loss of periodontal attachment compared with minimally leukotoxic strains. Another study by Cortelli et al. (45) recovered the highly leukotoxic genotype from young subjects with aggressive periodontitis and suggested a role for A. actinomycetemcomitans leukotoxic strains in the development of the disease, and possibly also in chronic periodontitis (74). Cortelli et al. (43, 44) proposed that the presence, in saliva, of leukotoxic strains of A. actinomycetemcomitans was a useful marker of aggressive periodontitis in children and adolescents. The association of the JP2 clone with aggressive periodontitis has also been documented outside Latin America (73, 89–92, 111). In a 2-year prospective study in Morocco, Haubek et al. (91) found that adolescents, who were initially free of periodontitis but harbored the JP2 clone, had a significantly higher relative risk (18.0; 95% CI: 7.8– 41.2) for developing destructive periodontal disease than did individuals infected with other types of bacteria (3.0; 95% CI 1.3–7.1). Aggregatibacter actinomycetemcomitans serotype c demonstrates low pathogenicity compared with the JP2 clone (serotype b), and individuals from Asia with little or no periodontal disease harbor predominantly strains of the c serotype (90, 188, 193). The highly leukotoxic JP2 clone seems to be particularly prominent in individuals of African descent, which may account, in part, for the observed high level of aggressive periodontitis in African-Americans and in black Latin-American people (39, 43–45). Different levels of the population with African ancestry may explain the different prevalence of A. actinomycetemcomitans and of the JP2 clonal type in Brazil (many people of African descent) (43–45) and Chile (few people of African descent) (76, 120). The

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A. actinomycetemcomitans leukotoxin may directly destroy polymorphonuclear leukocytes or may interact with host genetic-susceptibility factors (13, 54, 110, 118). The leukotoxin may be a particularly potent virulence factor in young individuals, who may not yet have developed effective immunity against the organism (92, 134, 142). However, individuals colonized by A. actinomycetemcomitans clones other than the JP2 clonal type can also develop periodontitis (6, 44, 74, 89, 137). Subgingival A. actinomycetemcomitans was detected in 26% of subjects with chronic periodontitis from the Umutina Indian Reservation at the Mato Grosso region of Brazil, and none of the A. actinomycetemcomitans isolates was of the leukotoxic phenotype (202). The cytolethal-distending toxin is another potential virulence factor of A. actinomycetemcomitans. In a study of 40 clinical isolates from Brazil, Kenya, Japan and Sweden (64), the three cdt genes (ABC) were detected in 34 of the 40 strains. One strain from Kenya did not possess cdtA or cdtB genes and expressed no toxic activity (64). Quantitative differences in cytotoxicity exist among cdt gene-containing strains, but no clear relationship has been found between cytolethal-distending toxin activity and periodontal disease status. The ‘red complex’ of bacteria (P. gingivalis, T. forsythia and T. denticola) (181) is found at elevated levels in Latin American patients with periodontitis (75, 76, 158) and peri-implantitis (167). Specifically, black-pigmented bacteria of the Porphyromonas and Prevotella species were detected in subjects with periodontitis (58%), gingivitis (37%) and healthy periodontium (15%) (42). ‘Orange complex’ pathogens, such as Fusobacterium species (201), and other groups of bacteria, such as Staphylococcus aureus (and even yeasts) may also contribute to chronic periodontitis (27, 117). Dental implants can harbor relatively unique bacteria, but may also share the microbiota of periodontitis (71, 167). Faveri et al. (65) suggested that tongue dorsum acts as a reservoir for periodontopathic bacteria and may be a source of microbial transmission and recolonization of periodontal sites. Feres et al. (69)

Periodontal microbiology in Latin America

recommended chlorhexidine oral rinse, along with scaling and root planning, to reduce periodontal pathogens in patients with periodontal disease. Recent findings from Argentina point to sodium hypochlorite (dilute bleach) oral rinse as an effective means of controlling dental biofilm and gingival inflammation (57). The low-cost bleach therapy could strengthen periodontal health efforts in poor rural and urban areas with limited access to professional dental care (174). Most studies on periodontal microbiology in Latin America have focused on the red complex of bacteria, with a particular emphasis on P. gingivalis. This microorganism is a major pathogen of chronic periodontitis and can also be involved in aggressive periodontitis (76, 113). Its average prevalence is 89% in periodontitis patients, 30% in gingivitis patients and 8% in periodontally healthy subjects (136). Porphyromonas gingivalis strains that possess a vast array of potent virulence factors are linked to severe periodontal disease, whereas P. gingivalis strains of reduced pathogenicity may be associated with minimal disease. The genetic polymorphism of the fimA gene, which encodes the subunit of P. gingivalis fimbriae, has attracted significant research interest because of the importance of fimbriae in adherence to host tissues (3). Six genetic types of fimA (I, Ib, II, III, IV and V) have been identified. Among these, type II, followed by type IV, predominated in periodontitis patients from Japan, China, Europe and a multiethnic population in Brazil, whereas fimAI strains predominantly inhabited healthy carriers (2, 3, 12, 136, 139, 198, 209). The most prevalent genotype in smokers was fimAIV, and that genotype was associated with clinical attachment loss and deep pocket depths. FimAIV was detected in 69.6% of infected periodontal sites with no difference between shallow and deep pockets (189). Six capsular serotypes have been identified in the P. gingivalis species, but a significant proportion of P. gingivalis isolates express little or no capsular material. All six capsular serotypes of P. gingivalis, except K1, were found in an Indonesian population, but no particular serotype was related to the extent of periodontal attachment loss (200). Likewise, studies in the USA showed that antibody responses to all six serotypes were common in both chronic and aggressive periodontitis (26). Virtually all (96%) subgingival isolates of P. gingivalis from an ethnically homogeneous Swedish population were phenotypically homogeneous in biochemical tests, enzyme profile and antibiotic susceptibility, and belonged to somatic antigen serotype A (53). To our knowledge, there are no reports from Latin America on P. gingivalis capsular serotypes.

The periodontal microbiota of special patient categories has been studied in Brazil. Tannerella forsythia was a prevalent periodontal species in HIV-positive patients, and Eikenella corrodens, D. pneumosintes, Streptococcus intermedius and C. rectus were also common periodontal isolates from patients with HIV/ AIDS (80, 83, 155). Patients with diabetes mellitus showed a periodontal microbiota that resembled that of non-diabetic individuals (51). Enterococcus faecalis was recovered from 42% of patients with periodontitis, and species of the Enterobacteriaceae family, such as Enterobacter cloacae, Klebsiella pneumoniae, Serratia marcescens, Enterobacter aerogenes and Escherichia coli, and even Archaea organisms, may also inhabit periodontitis lesions (15, 52, 66, 81, 115, 132, 185, 186). The presence of nonoral bacteria in periodontal sites may be related to immunosuppression, malnutrition, poor sanitary conditions, or an indiscriminate use of antibiotics. Studies from Brazil have examined the microbial relationship between periodontal disease and systemic diseases. Helicobacter pylori, which is involved in gastric ulcer and gastric cancer, can be recovered from saliva and from supragingival and subgingival plaque, suggesting that the oral cavity can serve as a reservoir for the organism (77, 168). Atheromatous plaque obtained from coronary arteries of periodontitis patients may contain periodontopathic bacterial DNA (126, 160). Periodontitis patients with inflammatory bowel disease (Crohn’s disease) harbored higher levels of periodontopathic bacteria than did control subjects (25). It may be that the interaction between periodontal and systemic diseases is a two-way street that can give rise to, respectively, nonoral and oral pathosis. Bacterial resistance to antimicrobial agents has been studied in Brazil. Avila-Campos et al. (7, 8) showed that A. actinomycetemcomitans was sensitive to mercuric chloride with a minimum inhibitory concentration of 4 mg/ml. Feres et al. (70) and Rodrigues et al. (159) evaluated the resistance of periodontal bacteria to metronidazole, amoxicillin and tetracycline. Actinomyces naeslundii type 2, Streptococcus mitis, Actinomyces odontolyticus and Streptococcus sanguinis were resistant to metronidazole. Prevotella nigrescens, Eubacterium saburreum, Prevotella melaninogenica and P. intermedia were resistant to amoxicillin. Actinomyces naeslundii type 1, Streptococcus constellatus and Streptococcus oralis were resistant to both metronidazole and amoxicillin. Species that were resistant to amoxicillin were also resistant to tetracycline. Clinical trials performed to compare different periodontal treatments have been conducted in Brazil.

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Matarazzo et al. (131) studied the clinical and microbiological effects of scaling and root planing, used alone or in combination with metronidazole, or in a combined metronidazole+amoxicillin therapy. Patients treated with scaling and root planing together with the two antibiotics experienced a reduction in the red and orange complexes of pathogens (131). A clinical trial by Novaes et al. (144) suggested that a combination of photodynamic therapy and scaling and root planing constituted a promising new approach to the nonsurgical treatment of aggressive periodontitis.

Colombia The first studies on periodontal infections in Colombia were performed by Jimenez and coworkers in 1975 and 1993, and reviewed in 2005 (106–108) (Table 2). These authors found that necrotizing ulcerative gingivitis was a precursor to noma (cancrum oris), and that low socio-economic status, acute herpetic gingivostomatitis, measles, leukemia, malnutrition and poor oral hygiene were associated with noma. Pathogenetic synergy between the major periodontal pathogens T. denticola and P. gingivalis, in combination with cytomegalovirus, may also contribute to the development of necrotizing oral diseases (37, 170, 172). The microbiota of chronic and aggressive periodontitis has been a major research emphasis in Colombia. Botero et al. (18) detected P. gingivalis, T. forsythia and E. corrodens in higher proportions in aggressive than in chronic periodontitis or in periodontal health (P < 0.05). Gram-negative enteric rods were frequent inhabitants of periodontitis lesions and, in particular, of aggressive periodontitis lesions (P < 0.01) (18). Martinez-Pabon et al. (130) determined that T. denticola was closely related to chronic periodontitis (P < 0.05), and they were able to identify the organism in patients’ saliva (129). A study in Bogota found that chronic and aggressive periodontitis lesions were associated with a high prevalence of P. gingivalis, T. forsythia, P. intermedia/P. nigrescens, C. rectus, Fusobacterium species and E. corrodens, and a relatively low prevalence of P. micra, A. actinomycetemcomitans, D. pneumosintes and gram-negative enteric rods (133). A multicenter study of periodontitis patients in the five largest Colombian cities found a high prevalence of P. gingivalis (72%), T. forsythia (59%), C. rectus (58%), A. actinomycetemcomitans (24%) and gram-negative enteric rods (35%) (113). Aggregatibacter actinomycetemcomitans was increased in aggressive periodontitis compared to

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chronic periodontitis (113). Tannerella forsythia, C. rectus and E. corrodens had a relatively low presence in periodontitis patients in the WestPacific and Central regions of Colombia, and gram-negative enteric rods occurrred with increased frequency in the Central region of Colombia (P < 0.05) (113). Another study recovered P. gingivalis and gram-negative enteric rods from subjects with chronic periodontitis at frequencies of 67% and 26%, respectively, and found the organisms to correlate positively with increased probing depth, clinical attachment loss and bleeding on probing (P < 0.001) (4). However, a longitudinal study of untreated periodontitis found that the gram-negative enteric rods were not consistantly observed in many subjects throughout a 1-month study period, indicating that gram-negative enteric rods are frequently transient microorganisms in subgingival sites (128). Apart from the enteric rods, other unusual microorganisms can also inhabit periodontal pockets, perhaps as superinfecting or transient occupants (15, 128). The periodontal microbiota of special patient categories has also been an important research topic in Colombia. In HIV-infected patients, Botero et al. (17) detected a higher frequency of periodontopathic bacteria in HIV-negative periodontitis patients than in HIV-positive periodontitis patients and in periodontally healthy subjects (P < 0.05), but HIV-positive patients harbored higher levels of superinfecting microorganisms, including Pseudomonas aeruginosa, E. cloacae and K. pneumoniae (P < 0.05). Castrillon et al. (32) studied the periodontal microbiota of diabetic patients. The red complex microorganisms (P. gingivalis, T. forsythia and T. denticola) were detected at a lower frequency in patients with diabetes, but A. actinomycetemcomitans occurred at an elevated level in diabetic patients (P < 0.05) (32). Porphyromonas gingivalis was associated with periodontitis in nondiabetic patients (P < 0.05), and A. actinomycetemcomitans was associated with periodontitis in diabetic patients (P < 0.05) (32). Contreras et al. (38) studied the periodontal microbiota in women with pre-eclampsia and periodontitis. Most patients with pre-eclampsia had chronic periodontitis (odds ratio = 3.0; 95% confidence interval: 1.91–4.87; P < 0.001), and P. gingivalis, T. forsythia and E. corrodens were more prevalent in pre-eclamptic subjects than in control subjects (P < 0.01). A variety of special dental conditions has been studied in Colombia. Botero et al. (21) found that implants with peri-implantitis harbored more P. gingivalis, P. intermedia/P. nigrescens and gram-negative enteric rods than did control implants (P < 0.05) (21).

Periodontal microbiology in Latin America

Table 2. Studies on the subgingival microbiota in Colombia Author

Year Subjects

Technique

Findings

Jimenez & Baer (106)

1975 28 patients with acute necrotizing ulcerative gingivitis

Clinical evaluation

Acute necrotizing ulcerative gingivitis occurred only in children from low socio-economic groups and was associated with poor oral hygiene and malnutrition. In the case of noma, previous infection with a virus or an intestinal parasite appeared to be important predisposing factors

Jimenez et al. (108)

2005 29 patients with necrotizing ulcerative gingivitis, 7 with necrotizing ulcerative periodontitis and 9 with noma

Clinical evaluation

Malnutrition and poor oral hygiene favored progression of the necrotic gingival lesion into deeper periodontal tissue and other structures of the oral cavity or of the facial tissues. The population presented predisposing and/or contributing factors such as acute herpetic gingivostomatitis, measles and leukemia. Necrotizing ulcerative gingivitis may progress to ulcerative necrotizing stomatitis, necrotizing ulcerative periodontitis and, finally, to noma

Botero et al. (18) 2007 68 patients with chronic Microbiological There was a higher frequency of Porphyromonas periodontitis, 12 with culture, PCR gingivalis, Tannerella forsythia and Eikenella aggressive periodontitis and corrodens in patients with aggressive 30 healthy subjects periodontitis than in those with chronic periodontitis and with healthy periodontium (P < 0.05). Gram-negative enteric rods were more frequent in patients with aggressive periodontitis (P < 0.01) Martinez-Pabon 2008 37 patients with chronic PCR et al. (130) periodontitis, 24 with aggressive periodontitis and 28 healthy subjects

The prevalence of Treponema denticola in patients with chronic periodontitis was significantly higher than in periodontally healthy subjects and in those with aggressive periodontitis (P < 0.05)

Martinez-Pabon 2010 97 patients with chronic PCR et al. (129) periodontitis and 51 healthy subjects

Salivary carriage of T. denticola may be a risk indicator for chronic periodontitis

Mayorga-Fayad et al. (133)

Microbiological Parvimonas micra, Aggregatibacter 2007 84 patients with chronic culture actinomycetemcomitans, Dialister pneumosintes periodontitis, 59 with and enteric rods (mostly Klebsielleae spp.) aggressive periodontitis and were recovered. P. gingivalis was isolated 40 healthy subjects more frequently than A. actinomycetemcomitans from patients with aggressive periodontitis

Lafaurie et al. (113)

PCR 2007 325 patients with chronic periodontitis, 158 with aggressive periodontitis and 137 healthy subjects

Ardila et al. (4)

2011 76 patients with chronic periodontitis

Frequency in periodontitis: P. gingivalis, 71.5%; T. forsythia, 58.5%; Campylobacter rectus, 57.5%; A. actinomycetemcomitans, 23.6%; and enteric rods, 34.5%. Porphyromonas gingivalis, T. forsythia and C. rectus were the most prevalent periodontopathic microorganisms in periodontitis patients from large Colombian cities

Microbiological Porphyromonas gingivalis and gram-negative culture enteric rods correlated positively with probing depth, clinical attachment level and bleeding on probing (P < 0.0001)

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Table 2. (Continued) Author

Year Subjects

Technique

Findings

Castrillon et al. (32)

2013 60 patients with diabetes mellitus and 62 nondiabetic patients

PCR

The red complex microorganisms occurred at a lower rate in patients with diabetes. The detection rate of A. actinomycetemcomitans was higher in patients with diabetes and periodontitis than in systemically healthy patients without periodontitis (P < 0.05). Porphyromonas gingivalis was associated with periodontitis in nondiabetic patients (P < 0.05)

Botero et al. (21)

2005 16 implants with signs of pocketing, 12 neighboring teeth and 11 nonneighboring teeth, in 11 patients

Significant correlations were found between Clinical, implants and neighboring teeth for gramradiographic and anaerobic negative enteric rods (P = 0.023), and between implants and non-neighboring teeth for culture study P. gingivalis (P = 0.042). The frequency of detection of gram-negative enteric rods (75%) and Prevotella intermedia/Prevotella nigrescens (25%) was higher in peri-implant lesions (P < 0.05). Porphyromonas gingivalis comprised 1.4% of total isolates in peri-implant lesions

Jaramillo et al. (101)

2005 60 periodontal abscesses from Microbiological Periodontal abscesses showed Fusobacterium 54 patients with chronic culture spp. (75%), P. intermedia/P. nigrescens (60%), periodontitis P. gingivalis (51%) and A. actinomycetemcomitans (30%). None of the bacteria tested presented resistance to azithromycin. An intermediate resistance was found for tetracycline in two of 14 isolates of P. intermedia/P. nigrescens and in three of four isolates of A. actinomycetemcomitans. One of 11 isolates of P. gingivalis was resistant to metronidazole. One isolate of A. actinomycetemcomitans and two isolates of P. intermedia/P. nigrescens were resistant to amoxicillin

Jaramillo et al. (102)

2013 192 patients with aggressive periodontitis and 256 with moderate periodontitis

PCR

Elevated levels of high-density lipoprotein (HDL) and triglyceride were present in patients with periodontitis. Serum IgG1 against P. gingivalis was associated with HDL-35. Serum IgG1 against T. forsythia was associated with triglyceride and serum IgG2. Aggregatibacter actinomycetemcomitans correlated with levels of HDL and HDL-35. The presence of IgG1 against P. gingivalis and A. actinomycetemcomitans correlated with reduced HDL levels

Moreno et al. (139)

2013 49 patients with chronic periodontitis, 77 with gingivitis and 25 healthy subjects

PCR

No difference among study groups was detected in the distribution of the P. gingivalis fimA genotype. An association was found among P. gingivalis, T. denticola and T. forsythia in patients with periodontitis

Jaramillo et al. (101) studied the microbiology of periodontal abscesses and found a high prevalence of Fusobacterium species (75%), P. intermedia/P. nigrescens (60%), P. gingivalis (51%) and A. actinomycetemcomitans (30%). Naranjo et al. (141) studied changes in the periodontal microbiota following orthodontic

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treatment. Orthodontic bracket placement caused an increase in plaque index, gingival index and bleeding on probing (P < 0.05), and an increase in P. gingivalis, P. intermedia/P. nigrescens, T. forsythia, and Fusobacterium species compared with controls (P < 0.01). Superinfecting E. cloacae, Klebsiella oxytoca,

Periodontal microbiology in Latin America

K. pneumoniae and Serratia marcescens were also detected after bracket placement (141). The systemic impact of periodontal disease was studied by Lafaurie et al. (114), who evaluated the frequency of subgingival anaerobic and facultative bacteria in the bloodstream following scaling and root planing of patients with severe generalized periodontitis. Eighty-one per cent of peripheral blood samples were positive for bacteria immediately after scaling, and the periodontopathic microorganisms most frequently identified were P. gingivalis and P. micra, and organisms less often isolated were Campylobacter species, E. corrodens, T. forsythia, Fusobacterium species and P. intermedia. In a similar study, Castillo et al. (31) identified bacteria in peripheral blood after scaling and root planing in 55% of periodontitis patients; P. gingivalis and A. actinomycetemcomitans were the periodontal pathogens most frequently identified. Jaramillo et al. (102) studied the relationship between untreated periodontal disease and low-grade systemic inflammation and blood lipid alteration. A high IgG1 level against P. gingivalis and A. actinomycetemcomitans may correlate with a reduced level of the anti-atherogenic high-density lipoprotein (102). Moreno et al. (139), in a recent study of P. gingivalis fimA genotypes, found no differences in genotype distribution among chronic periodontitis, gingivitis and healthy periodontium. Microbial antibiotic resistance was determined by Jaramillo et al. (103) in isolates from patients with aggressive periodontitis and chronic periodontitis and from periodontally healthy subjects. Aggregatibacter actinomycetemcomitans was resistant to metronidazole, amoxicillin and clindamycin, and P. intermedia/nigrescens and Enterobacteriaceae species were resistant to amoxicillin (103). Finally, Ramirez et al. (154) found an increased level of important cardiovascular markers and red complex bacteria in patients with severe and moderate chronic periodontitis.

Chile Lopez et al. (121) studied the microbiota of chronic periodontitis in Chilean patients using the checkerboard DNA–DNA hybridization technique (Table 3). The main findings were high proportions of the red complex bacteria P. gingivalis, T. forsythia, and T. denticola, and variable levels of the periodontopathic microorganisms C. rectus, F. nucleatum, P. micros and Treponema socranskii (121). A study of aggressive periodontitis found a low prevalence of Actinomyces species, which are considered commensal organisms

in the subgingival area (119). Gajardo et al. (76) determined the predominant periodontopathic bacteria to be P. gingivalis, C. rectus, E. corrodens, P. micra and Capnocytophaga species. Silva et al. (169) compared the occurrence of A. actinomycetemcomitans, P. gingivalis and T. forsythia in progressive and stable periodontitis, and found a higher percentage of P. gingivalis in disease-active sites (18%) than in disease-inactive sites (2%). Lopez et al. (123) studied the consortia of microorganisms associated with periodontitis in different stages of the disease. Prevotella nigrescens, P. intermedia, P. gingivalis and T. forsythia were present at high levels in subjects with periodontitis. One cluster of organisms included T. forsythia, C. rectus, P. gingivalis, P. intermedia, P. nigrescens, P. micra and T. denticola. Another cluster of organisms contained Actinomyces oris, Capnocytophaga ochracea, E. corrodens, S. intermedius, S. noxia, S. oralis, S. sanguinis and Veillonella parvula. Fusobacterium nucleatum was assigned to both clusters. The personal cluster of periodontal bacteria may be an important determinant of the outcome of periodontal therapy (165). Lopez et al. (122) also evaluated the clinical and microbiological effects of treating periodontitis solely with metronidazole plus amoxicillin. They found a marked reduction in the mean counts of the red complex bacteria P. gingivalis, T. forsythia and T. denticola for up to 12 months post-treatment in both the antibiotic-treated group and the scaled control group. Actinomyces counts increased significantly post-treatment. The authors made the interesting observation that the antibiotic therapy and periodontal scaling and root planing led to similar improvements in clinical and microbiological variables (122).

Mexico The subgingival microbiota has been described in patients from Mexico using the checkerboard DNA– DNA hybridization technique (Table 4). Consistent with other studies, periodontitis patients presented higher quantities of P. gingivalis, T. denticola, T. forsythia and A. actinomycetemcomitans than did periodontally healthy subjects (1, 206). No significant differences were observed in the detection level of 40 test species between generalized aggressive periodontitis and generalized chronic periodontitis. The bacterial species that were associated with periodontitis were also detected in periodontally healthy subjects (205, 206). Another study detected subgingival P. intermedia in 89%, and subgingival P. gingivalis in 58%,

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Table 3. Studies on the subgingival microbiota in Chile Author

Year Subjects

Technique

Findings

Lopez 2004 26 patients with chronic Checkerboard DNA–DNA et al. (121) periodontitis from Chile and hybridization the USA

Red complex and other periodontopathic microorganisms such as Campylobacter rectus, Fusobacterium nucleatum, Parvimonas micra and Treponema socranskii, as well as yellow complex bacteria, were significantly elevated in Chilean subjects, whereas Actinomyces spp. were higher in US subjects

Gajardo 2005 36 patients with aggressive et al. (76) periodontitis from Chile

Microbiological culture

Campylobacter rectus, Porphyromonas gingivalis, Eikenella corrodens, P. micra and Capnocytophaga spp. were predominant in aggressive periodontitis lesions, but only C. rectus was statistically associated with periodontitis

Silva 2008 56 patients with chronic et al. (169) periodontitis from Chile

ELISA, anaerobe microbiological culture

Higher RANKL, interleukin-1beta and matrix metalloproteinase-13 activity levels were observed in disease-active sites (P ≤ 0.05). The proportion of P. gingivalis, Aggregatibacter actinomycetemcomitans and Tannerella forsythia, and the number of CD4+ T cells, were higher in disease-active than in inactive periodontal sites

Lopez 2006 22 patients with chronic et al. (122) periodontitis

Clinical trial, Checkerboard Metronidazole plus amoxicillin or scaling DNA–DNA hybridization and root planing were given to patients with periodontitis harboring high percentages of Streptococcus gordonii, A. actinomycetemcomitans, Eubacterium nodatum, Fusobacterium periodonticum, P. gingivalis, Treponema denticola and T. socranskii. At 12 months posttreatment, changes in clinical and microbiological parameters were similar in subjects receiving systemic antibiotics or scaling and root planing

Haffajee 2004 300 subjects from the USA, et al. (86) Sweden, Brazil and Chile (total number of samples=6036)

Checkerboard DNA–DNA hybridization

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Porphyromonas gingivalis, comprised adjusted means of 7.5, 11.9, 1.6 and 6.6% of the microbiota in subjects from Brazil, Chile, Sweden and USA (P < 0.001), and mean proportions of T. denticola were 6.7, 4.2, 0.8 and 2.3, respectively (P < 0.001). Tannerella forsythia mean proportions ranged from 6.2 to 8.5% and did not differ significantly among countries. Actinomyces naeslundii genospecies 1 and 2 (8.4% and 7.2% respectively) and Prevotella intermedia (6.5%) were prominent species in Brazil; Prevotella melaninogenica (6.4%) and Neisseria mucosa (5.3%) were prominent in Chile; A. naeslundii genospecies 2 (8.4%), Capnocytophaga gingivalis (7.1%) and P. micra (5.0%) were prominent in Sweden; A. naeslundii genospecies 2 (7.5%), Prevotella intermedia (6.8%) and Capnocytophaga gingivalis (6.1%) were prominent in the USA

Periodontal microbiology in Latin America

Table 3. (Continued) Author

Year Subjects

Herrera 2008 114 patients with chronic et al. (94) periodontitis

Technique

Findings

Anaerobic microbiological Aggregatibacter actinomycetemcomitans culture (19.4%), Prevotella intermedia (19.4%), Tannerella forsythia (16.2%), Capnocytophaga spp. (13.5%), P. micra (29.7%), E. corrodens (34.3%), P. gingivalis (83.8%), Fusobacterium spp. (63.9%) and superinfecting enterics (17.6%) were detected in chronic periodontitis of Chilean patients

of patients with periodontitis and rheumatoid arthritis (127). The same microorganisms were detected by PCR in synovial fluid of subjects with periodontitis and rheumatoid arthritis (74% and 42% respectively), but not by culture (127). A study using a multiplexPCR protocol found P. gingivalis in subjects with chronic periodontitis (37%) as well as with a normal periodontium (24%) (56). Davila-Perez et al. (55) studied the distribution of P. gingivalis fimA genotypes in type 2 diabetic patients with periodontitis and in nondiabetic patients with and without periodontitis. The diabetic patients harbored manly the fimAI, II and III genotypes, the nondiabetic patients harbored the fimAI, Ib and II genotypes, and the periodontally healthy subjects harbored the fimAI genotype (55).

Various countries The periodontal microbiota has also been studied in Argentina, the Dominican Republic, Guatemala, Haiti, Panama and Venezuela (Table 5). In Argentina, A. actinomycetemcomitans, red complex bacteria and superinfecting organisms were prevalent in patients with periodontitis (11, 28, 46, 47, 59, 138, 197). Bazzano et al. (11) found that scaling and root planing reduced the occurrence of P. gingivalis, T. forsythia and T. denticola in deep periodontal pockets and that no further loss of clinical attachment was observed for 12 months in 79% of the treated sites. In the Dominican Republic, gram-negative enteric rods were prevalent in untreated periodontal sites (178). In Guatemala, Pomes et al. (151) identified A. actinomycetemcomitans, yeast and Entamoeba gingivalis as risk indicators of adolescent periodontitis. A high prevalence of A. actinomycetemcomitans was also demonstrated in black Panamanian patients with localized juvenile periodontitis (61). Two studies from Venezuela described periodontal pathogens in patients with gastritis and HIV infection (14, 24).

A few studies have compared the periodontal microbiota among different countries in Latin America and abroad. Haffejee et al. (86), using checkerboard DNA–DNA hybridization, found elevated levels of P. gingivalis and T. denticola in Brazil and Chile compared with Sweden and the USA. Samples from Chileans of low socio-economic status harbored relatively high proportions of Streptococcus gordonii, A. actinomycetemcomitans, Eubacterium nodatum, Fusobacterium periodonticum, P. gingivalis, T. denticola and T. socranskii, and low percentages of A. naeslundii and C. gracilis (86). Herrera et al. (94) studied the microbiota of patients with chronic periodontitis in Colombia, Chile and Spain. Patients from Colombia revealed greater severity of periodontitis, significantly higher total bacterial colony counts, and increased levels of P. gingivalis and gram-negative enteric rods. Chilean patients showed a high prevalence of P. micra and E. corrodens and relatively low percentages of A. actinomycetemcomitans, P. intermedia, T. forsythia and Capnocytophaga species. Spanish patients exhibited increased levels of P. intermedia and did not yield gram-negative enteric rods. The study suggested that differences exist in the periodontopathic microbiota of subjects in these three countries. Aggressive periodontitis in adolescents (i.e. patients with localized juvenile periodontitis) has been related to A. actinomycetemcomitans and P. gingivalis. The classic type of localized juvenile periodontitis starts at the onset of puberty and involves first molars and incisors and exhibits very little dental plaque and virtually no gingivitis. This type of disease typically harbors A. actinomycetemcomitans at a prevalence of 73–100% (180). Another type of localized juvenile periodontitis shows the characteristic first molar-incisor tissue destruction, but also manifests distinct plaque accumulation and gingivitis and tends to appear in slightly older patients. This type of disease has been studied in Jamaica (135) and Colombia (18, 22, 113) and is predominated by P. gingivalis, which may

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Table 4. Studies on the subgingival microbiota in Mexico Author

Year Subjects

Technique

Almaguer-Flores et al. (1)

2005 33 patients with chronic periodontitis; 23 healthy subjects

Checkerboard The presence of bacterial DNA for DNA–DNA Porphyromonas gingivalis, Tannerella hybridization forsythia, Treponema denticola and Aggregatibacter actinomycetemcomitans was significantly higher in subjects with chronic periodontitis. Lower proportions of Actinomyces spp. and microorganisms included in the yellow complex were found in patients with chronic periodontitis than in healthy subjects

Ximenez-Fyvie et al. (205)

2006 19 patients with generalized aggressive periodontitis; 39 patients with generalized chronic periodontitis; 19 healthy subjects

Checkerboard Patients with generalized aggressive DNA–DNA periodontitis and patients with generalized hybridization chronic periodontitis harbored significantly higher levels of P. gingivalis, T. forsythia and Prevotella nigrescens than did healthy subjects. No significant differences in any of 40 microbial species were detected between untreated generalized aggressive periodontitis and untreated generalized chronic periodontitis

Ximenez-Fyvie et al. (206)

2006 44 patients with chronic periodontitis; 20 healthy subjects

Checkerboard No significant differences were detected in DNA–DNA the percentage of carriers of any of the hybridization species tested. The proportions of P. gingivalis, T. forsythia and red complex species (P. gingivalis, T. forsythia and T. denticola) were also significantly higher in patients with periodontitis

Martinez-Martinez et al. (127)

2009 19 patients with chronic periodontitis and rheumatoid arthritis

PCR

De La Garza-Ramos 2008 65 patients with chronic et al. (56) periodontitis; 17 healthy subjects

Davila-Perez et al. (55)

Subgingival plaque and synovial fluid yielded Prevotella intermedia (89.4% and 73.6%, respectively) and P. gingivalis (57.8% and 42.1%, respectively). Culture did not show any bacterial growth

Multiplex-PCR In untreated patients with periodontitis, 37% yielded P. gingivalis, 17% yielded Streptococcus intermedius, and 24.5% yielded both species. Porphyromonas gingivalis was detected in 23.5% of healthy volunteers, whereas Streptococcus intermedius was not detected in healthy individuals

PCR 2007 25 healthy subjects; 25 patients with chronic periodontitis; 25 patients with type 2 diabetes mellitus and chronic periodontitis

occur as a superinfection or independently of an A. actinomycetemcomitans infection. Studies in Chile of patients with localized juvenile periodontitis yielded A. actinomycetemcomitans at prevalences of 39–44%, but also P. gingivalis and P. intermedia at relatively high levels (119, 120).

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Findings

Porphyromonas gingivalis genotypes were analyzed. In healthy subjects, type I fimA was the most frequently detected individual genotype (40%). In subjects with periodontitis, the most frequently detected individual fimA genotype was Ib (20%). In periodontitis patients with type 2 diabetes mellitus, the most frequently detected genotypes were types I and III fimA (20%)

Human viruses and periodontal disease Herpesviruses and other human viruses are often acquired in childhood and can be identified in the oral cavity of most adult individuals (Table 6). Herpesviruses employ various strategies to interact with

Periodontal microbiology in Latin America


, Hait
ı and Venezuela Table 5. Studies on the subgingival microbiota in Argentina, Guatemala, Panama Country and Author Year Subjects

Technique

Findings

Argentina Canigia et al. (28)

1999 45 patients with chronic periodontitis

Microbiological In 138 periodontitis sites, the most prevalent species culture were Prevotella intermedia/Prevotella nigrescens (77%), followed by Aggregatibacter actinomycetemcomitans (44%) and Parvimonas micra (39%). Porphyromonas gingivalis was detected in 26% of the sites, and was associated with a greater depth of periodontal pockets. Healthy periodontal sites yielded mainly viridans streptococci and Neisseria spp. and the previously mentioned species were not detected

Cuesta et al. (46)

2010 82 patients with periodontal disease

Microbiological The prevalence of Staphylococcus spp. was 42.7% in culture periodontal pockets and 69.5% in the oral mucosa, and the prevalence of Candida spp. was 25.6% in periodontal pockets and 42.7% in the oral mucosa. The coexistence of these species was 13.4% in periodontal pockets and 36.6% in the oral mucosa. Staphylococcus aureus occurred in 13.4% of the periodontal pockets and 13.5% in the oral mucosa. Candida albicans was detected in 76.2% of the periodontal pockets and in 63% of oral mucosa

Cuesta et al. (47)

2011 102 patients with periodontitis and gingivitis

Microbiological Staphylococcus aureus was found in 10.8% (n = 11) of culture and periodontal pockets and in 19.6% (n = 20) of the PCR oral mucosa. This species may behave as an opportunistic pathogen that can colonize the gingival sulcus, finding an ecological niche that provides optimal conditions for infection

Monetti et al. (138)

2012 Six patients with gingivitis, 7 with mild chronic periodontitis, 23 with moderate chronic periodontitis and 7 with severe periodontitis

PCR

Prevotella denticola + P. intermedia (P = 0.04) and P. intermedia + Tannerella forsythia (P = 0.02) were associated with the presence of tumor necrosis factor-alpha mRNA in 20% and 25% of subjects, respectively. Porphyromonas gingivalis + A. actinomycetemcomitans and A. actinomycetemcomitans + T. forsythia were associated with severe periodontal disease and clinical attachment loss, respectively. The association between the presence of P. intermedia and expression levels of tumor necrosis factor-alpha was significant (P = 0.05)

Bazzano et al. (11)

2012 44 sites from 11 patients with chronic periodontitis

PCR

Porphyromonas gingivalis, T. forsythia and Treponema denticola occurred at baseline in 66%, 55% and 41%, respectively, of the test sites. Deep pockets correlated with T. forsythiaTreponema denticola (6.8 mm) and T. forsythiaT. denticola-P. intermedia (7 mm)

Usin et al. (197)

2013 150 pregnant women

PCR

A high prevalence of P. gingivalis was found in pregnant women, especially in combination with T. forsythia and T. denticola. Older age was a risk factor for moderate periodontitis (odds ratio = 4.92, 95% confidence interval = 1.1–21.3, P = 0.0328). In pregnant women, the presence of P. gingivalis was found to increase the risk for showing a clinical attachment level >5 mm and for moderate periodontitis

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Table 5. (Continued) Country and Author Year Subjects

Technique

Findings

Dominican Republic Slots et al. (178)

1991 24 patients with periodontitis

Microbiological Direct microscopic examination revealed that cocci culture and nonmotile organisms made up 85% of the total organisms and spirochetes as little as 3%. Nonselective culture showed gram-negative organisms to constitute 53% of total isolates. Fusobacterium nucleatum averaged 15%, blackpigmented anaerobes 7% and Parvimonas micra 10% of the cultivable microflora. Enteric rods and acinetobacter species were recovered from 16 patients and comprised 23% of the cultivable flora. The most common enteric species were Enterobacter cloacae, Klebsiella oxytoca and 7 other species

Dowset et al. (59)

2002 114 subjects from 45 families

Checkerboard Streptococcus sanguis, Actinomyces naeslundii DNA–DNA genospecies 2 and Fusobacterium nucleatum were hybridization significantly more common in deep periodontal pockets, and A. naeslundii and P. micra were significantly more common in healthy periodontal sites. Aggregatibacter actinomycetemcomitans was not detected in any sample

Pomes et al. (151)

2000 62 subjects, 11–15 years Different tests of age for each pair of sites

The prevalence of BANA-positive test results (red bacteria indicator) was 77%, of A. actinomycetemcomitans was 47%, of yeasts was 43% and of Entamoeba gingivalis was 21%. The risk for severe gingival inflammation and/or increased probing depth was 1.5 and 5.2 times higher with a positive BANA test or A. actinomycetemcomitans test. No associations were found for yeasts and E. gingivalis

2011 104 Haitian adolescents

Quantitative PCR

The frequency of Streptococcus mutans was 67.3% in supragingival plaque samples, and A. actinomycetemcomitans had a frequency of 85.1% in subgingival plaque samples

Eisenmann et al. (61)

1983 12 patients with localized juvenile periodontitis and 10 with gingivitis

Microbiological Aggregatibacter actinomycetemcomitans was present culture in all localized juvenile periodontitis lesions studied and was, on average, recovered in hundred-fold higher numbers from localized juvenile periodontitis lesions than from gingivitis lesions. Capnocytophaga was only recovered in approximately threefold higher numbers from localized juvenile periodontitis than from gingivitis

Wiebe et al. (204)

2003 18 individuals with Kindler syndrome

PCR

Guatemala

Haiti Psoter et al. (153)

Panama

74

Kindler syndrome periodontitis yielded a prevalence of 54% for T. denticola, 46% for P. nigrescens, 31% for Dialister pneumosintes, 31% for P. gingivalis, 23% for A. actinomycetemcomitans and 15% for T. forsythia

Periodontal microbiology in Latin America

Table 5. (Continued) Country and Author Year Subjects

Technique

Findings

Venezuela Berroteran et al. (14)

2002 32 patients with chronic PCR gastritis and 20 healthy subjects

Helicobacter pylori was detected in antral samples from 24 (75%) of 32 patients with chronic gastritis. Helicobacter pylori was also detected in dental plaque samples of 12 (37.5%) of the 32 patients. Seven patients with chronic gastritis yielded H. pylori in both antral and dental plaque samples. There was no positive relationship between H. pylori and periodontal parameters

Brito et al. (24)

2008 32 HIV-positive and 16 PCR HIV-negative patients

The mean values of plaque index, gingival index and clinical attachment loss were similar for HIV-infected patients undergoing or not receiving HAART therapy. Linear gingival erythema was observed in HIVinfected patients, and necrotizing ulcerative periodontitis occurred only in HIV-positive patients without HAART therapy. Prevotella intermedia was the most frequently recovered microorganism. Porphyromonas gingivalis was observed only in one (5%) HIV-positive patient receiving HAART therapy. The periodontal indexes were not related with the CD4+ count or viral load

Escalona et al. (63)

2011 20 HIV-positive patients PCR with periodontal disease and 7 HIVnegative patients with periodontal disease

Human papillomaviruses were detected in 46% of HIV-positive patients under therapy. The CD4 cell counts in the human papillomaviruspositive patients were not significantly different from those in the human papillomavirus-negative group. Genotypes 6 and 11 were observed in the human papillomavirus-positive samples, of which 4 (66.6%) of six presented a co-infection with both types. No significant differences in the periodontal conditions were observed between patients with human papillomavirus + HIV infection compared with patients infected with HIV only. Papillomaviruses were detected only in the gingival crevicular fluid of HIV-positive patients under HAART, independently of the periodontal condition

and subvert host defenses to ensure their continued existence and propagation (173). Herpesvirus infections vary considerably in severity, which can range from subclinical infection to encephalitis and cancer, including carcinoma, lymphoma and sarcoma (179). Genomes of herpes simplex virus type 1, human cytomegalovirus and Epstein–Barr virus have been detected in periodontal pockets (22, 23, 40, 83), saliva (179) and gingival immune cells (36, 41, 98), and the three herpesviruses have been associated with chronic periodontitis (22, 40), aggressive periodontitis (203), acute necrotizing ulcerative gingivitis (37) and periodontal abscesses (50, 164). Herpesviruses can occasionally be present at low levels in healthy periodontal sites (22, 23, 82, 179). In Colombia, Botero et al. (23) cultured cytomegalovirus from the gingival crevicular fluid of patients

with periodontitis, but with a lower yield than that obtained by molecular identification. Cytomegalovirus was detected in patients with periodontitis (53%) and in periodontally healthy subjects (18%) (P < 0.05), and cytomegalovirus-positive sites showed a higher occurrence of major periodontopathic bacteria and more loss of periodontal attachment compared with cytomegalovirus-negative sites (22). Botero et al. (19) studied the in vitro effect of human cytomegalovirus infection on gingival fibroblast expression of collagen I and III and matrix metalloproteinases 1 and 2. Gingival fibroblasts infected with human cytomegalovirus exhibited reduced expression of mRNA for collagens I and III (P < 0.05), and up-regulation of mRNA expression for matrix metalloproteinases 1 and 2 (P < 0.05). Botero et al. (19) also found higher expression of mRNA for collagens I and III in biop-

75

76

Brazil

Grande et al. 2008 (82) 50 HIV-positive patients with chronic periodontitis and 50 HIV-negative control patients

40 patients with chronic periodontitis

14 patients with chronic periodontitis and 3 healthy subjects

Brazil

Colombia

Botero et al. 2008 (19)

20 patients with chronic periodontitis, 10 patients with aggressive periodontitis and 22 healthy subjects

Imbronito et al. 2008 (98)

Colombia

Botero et al. 2007 (22)

37 patients with chronic periodontitis, 7 patients with aggressive periodontitis and 24 healthy subjects

30 patients with aggressive periodontitis

Colombia

Botero et al. 2008 (23)

Number of subjects

Watanabe Brazil et al. 2007 (203)

Country

Author/year

Table 6. Subgingival detection of mammalian viruses in Latin America

Subgingival plaque: HIV+: 72% HIV : 48% Saliva: HIV+: 62% HIV : 40% Blood: HIV+: 18% HIV : 24%

Subgingival plaque: 45% Saliva: 37.5% Blood: 25%

Periodontitis sites: 57% Gingivitis sites: 30%

Epstein–Barr virus-1

Virus

Subgingival plaque: HIV+: 82% HIV : 80% Saliva: HIV+: 72% HIV : 80% Blood: HIV+: 68% HIV : 84%

Subgingival plaque: 82.5% Saliva: 75% Blood: 82.5%

Prevalence: 6%

Gingival biopsies from human cytomegalovirus-positive individuals with periodontitis had higher expression of mRNA for collagens I and III compared with biopsies from human cytomegalovirus-negative individuals

Chronic periodontitis: 60% Aggressive periodontitis: 40% Healthy patients: 18.1%

Periodontitis: PCR: 79.5% Real-time PCR: 47.7% Culture: 2.3% Healthy subjects: PCR: 25% Real-time PCR: 4.1%, Culture: 0%

Human cytomegalovirus

Subgingival plaque: HIV+: 6% HIV : 16% Saliva: HIV+: 18% HIV : 24% Blood: HIV+: 6% HIV : 8%

Herpes simplex virus type 1

Contreras et al.

46 patients with chronic periodontitis and type 2 diabetes

Brazil

Venezuela 20 HIV-positive patients with chronic periodontitis, 7 HIV-negative patients with chronic periodontitis and 7 HIV-negative subjects with healthy periodontium

Casarin et al. 2010 (29)

Escalona et al. 2011 (63)

27 HIV-positive patients with chronic periodontitis and 23 HIV-positive patients with gingivitis

50 patients with chronic periodontitis and 50 healthy subjects

Brazil

Grande et al. 2011 (83)

Number of subjects

Nishiyama Brazil et al. 2008 (143)

Country

Author/year

Table 6. (Continued)

Subgingival plaque: Periodontitis: 3.7% Gingivitis: 8.7% Saliva: Periodontitis: 14.8% Gingivitis: 17.4% Blood: Periodontitis: 0% Gingivitis: 13%

Subgingival plaque: Periodontitis: 74% Gingivitis: 91.3% Saliva: Periodontitis: 77.7% Gingivitis: 65.2% Blood: Periodontitis: 74.1% Gingivitis: 60%

Chronic periodontitis: 3.4% Healthy periodontium: 0%

Herpes simplex virus type 1

Human cytomegalovirus

Glycemic control did not influence A higher frequency of the frequency of human Epstein–Barr virus in cytomegalovirus shallow periodontal pockets of patients with poorly controlled diabetes

Subgingival plaque: Periodontitis: 70.4% Gingivitis: 78.3% Saliva: Periodontitis: 81.5% Gingivitis: 52.2% Blood: Periodontitis: 22% Gingivitis: 13%

Epstein–Barr virus-1

Virus

Periodontal microbiology in Latin America

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Contreras et al.

sies from cytomegalovirus-positive individuals with periodontitis than in biopsies from cytomegalovirusnegative patients with periodontitis. The ability of cytomegalovirus to upregulate the expression of mRNA for collagens and metalloproteinases may contribute to the development of periodontitis. Other pathways by which herpesviruses may cause periodontitis include direct cytopathic effects on fibroblasts, keratinocytes and other types of cells (19, 20, 40, 83) and synergistic pathogenetic interactions with periodontopathic bacteria (22, 172, 179). In Brazil, Watanabe et al. (203) detected Epstein– Barr virus-1 in 57% of sites with aggressive periodontitis and in 30% of sites with gingivitis; the relative risk for periodontitis was 3.05 with a confidence interval of 1.43–6.47. Cytomegalovirus was found in 6% of the study individuals (203). Imbronito et al. (98) identified Epstein–Barr virus-1 in 45% of chronic periodontitis samples, 38% of salivary samples and 25% of peripheral blood samples. Cytomegalovirus was detected in 82% of the periodontitis and blood samples and in 75% of the saliva samples (98). Grande et al. (82), in a study of HIV-infected subjects, found cytomegalovirus in 82% of periodontitis sites of HIVpositive and in 80% of periodontitis sites of HIV-negative patients, and Epstein–Barr virus-1 in 72% of periodontitis sites of HIV-positive and in 48% of periodontitis sites of HIV-negative patients. In another study of HIV, Grande et al. (83) detected cytomegalovirus and Epstein–Barr virus-1 in, respectively, 74% and 70% of periodontitis samples, in 77% and 81% of salivary samples, and in 74% and 22% of peripheral blood samples. Herpes simplex-1 virus occurred with a frequency of 4% in periodontitis samples and 15% in salivary samples, and was not detected in blood samples (83). Nishiyama et al. (143) also found a low occurrence (3%) of herpes simplex-1 virus in periodontitis lesions. Casarin et al. (29) studied the relationship between herpesviruses and periodontal status in patients with type 2 diabetes and found Epstein–Barr virus in 81% of shallow periodontal sites of patients with poor glycemic control and in 43% of shallow periodontal sites of patients with good glycemic control (P = 0.05). Cytomegalovirus occurred in 33–43% of shallow periodontal sites, with no preference for poorly controlled diabetes (29). The elevated prevalence of herpesviruses in periodontal sites of patients with type 2 diabetes may partly explain the elevated risk of these patients for developing periodontitis. Human viruses other than herpesviruses can also reside in the periodontium. Escalona et al. (63) in Venezuela studied the presence of human papilloma-

78

virus in periodontal pocket samples of HIV-infected patients. Papillomavirus was detected in 46% of HIVpositive patients receiving anti-retroviral treatment, but was not found in HIV-seronegative patients (63). Horewicz et al. (95) did not detect the oncogenic papillomavirus type 16 in samples from chronic periodontitis, gingivitis or healthy periodontium. Lins et al. (116) found that individuals orally infected with the human T-lymphotropic virus type I were more affected by periodontitis than were noninfected controls.

The future of periodontal microbiology in Latin America A healthy periodontium is important for overall oral health, but the increasing evidence that periodontitis also can have systemic consequences raises treatment of periodontal disease to a new level of importance (38, 102, 154, 197). Periodontal disease has a global distribution, but is particularly prevalent and severe in low-income individuals. Many periodontitis patients of Central and South America do not receive adequate periodontal therapy because of economic and social constrains and a scarcity of affordable dental services. There is a need to find safe and effective methods to control periodontal infections in Latin American populations with limited access to professional dental care. Knowledge of the periodontal microbiota is critical for implementing a successful periodontal therapy. Periodontal therapy aims to control periodontopathic microorganisms by means of mechanical pocket debridement, periodontal pocket irrigation with potent antiseptics, treatment of advanced disease with systemic antibiotics and attention to proper selfcare. The worldwide increase in antibiotic-resistant bacteria and the high costs of new, effective antibiotics have created interest in the use of inexpensive antiseptics to combat periodontal infections. Antiseptics are broad-spectrum microbicidal agents that are applied topically onto living tissue to prevent or treat clinical infections caused by bacteria, yeasts and viruses (174, 175). Unlike antibiotics, antiseptics destroy periodontal bacteria and viruses in a nondiscriminative manner and can cover the entire spectrum of traditional periodontal pathogens, gramnegative enteric rods and superinfecting organisms (190, 191). Low-cost periodontal therapy, based predominantly on antiseptic agents, may help to meet the unmet treatment needs of large impoverished populations in Latin America (57, 174, 175).

Periodontal microbiology in Latin America

Although research in periodontal microbiology is steadily increasing in Central and South America, several research issues in periodontology remain unresolved and merit attention. It is critical to establish a clear definition of periodontal diseases and proper periodontal diagnoses to make studies comparable. Studies that compare the microbiology of periodontal disease in various socio-economic groups have yet to be undertaken in most Latin American countries. Microbiological risk factors for periodontal disease and effective periodontal treatments remain to be identified for immunocompromised and noncompromised patients. And finally, the growing realization that periodontal infections may give rise to systemic illness, perhaps especially in immunocompromised individuals, ought to be a high-priority research topic. Significant progress in molecular microbiology has made such studies possible, even in low-budget laboratories. Continued research in periodontal microbiology is poised to generate discoveries that can form the basis for more effective approaches to the prevention and treatment of destructive periodontal disease in Latin America.

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