Microbiology of Endodontic

 

• Learning Objective

  • Pathway of infection
  • Correlation of Microbes to infection
  • Microflora in intraradikular and ekstraradikular infection
  • Microflora involved in persistent infection
  • Bacterial biofilms

• Introduction

  Preservation of teeth by endodontic therapy has gained lot of popularity because of increased and predictable success rate of endodontic procedures

  a complete understanding of endodontic pathology and the abilities of the dentist is required

• Endondontic Infection

  • What is it

    Endodontic infection is the infection of the dental root canal system

    • infeksi

      perkembangbiakan suatu agen infeksius pada tubuh

    • where

      • jaringan pulpa
      • jaringan periapikal

• Goals of endodontic treatment

  • eradicate the infection (hilangkan)
  • prevent microorganisms from infecting or re-infecting the root and/or periradicular tissues. (cegah)

• Pathway of infection

  • Dentinal tubules (0,2mm)

    sisa dentin (itulah kenapa sudah pulp capping masih bisa kena infeksi)

    • karies profunda

  • Open cavity

    • traumatis
      • fraktur mahkota
    • iatrogenik

  • Periodontal membrane

    mikroorganisme dari sulcus gingiva melalui saluran lateral/ foramen apikal

    • saat kegoyangan gigi, perpindahan ketika pembentukan periodontal pocket

  • Blood stream

    bakteri transient (keberadaan sementara bakteri)

    • karena kondisi kesehatan, bakteri dalam darah tertarik ke pulpa biasanya setelah prosedur trauma atau operasi yang menghasilkan inflamasi
    • daya tarik menjadi PD/ Pgetah bening jalur infeksi endo

  • Faulty restoration

    kontaminasi saliva dari oklusal bisa apikal (60%)

    jika tumpatan salah→ akses

  

• CORRELATION OF MICROBES TO INFECTION

  • Endodontic infections

    polymicrobial nature (beragam spesies)

  • Obligate anaerobic bacteria → dominan

    dominating the microbiota in primary infections.

    • tidak perlu O2 samsek

  • There are various microorganisms related to intra-radicular and extraradicular infections and organisms involved in persistent infection.

Microflora in intraradikular and ekstraradikular infection

• Intraradicular infections

  • intraradicular microorganism usually constrain themselves in the root canal due to the defense barrier (membatasi di saluran akar krn gabisa lewat)
  • Gram negative

    • Bacteroides melaninogenicus (Black pigmented Gram negative anaerobic rods)

      • Prevotella spp
        • Prevotella intermedia
        • Prevotella nigrescens
        • Prevotella tannerae
        • Prevotella multissacharivorax
        • Prevotella baroniae and
        • Prevotella denticola
      • Porphyromonas spp
        • Porphyromonas endodontalis
        • Porphyromonas gingivalis → periodontitis

    • Fusobacterium spp

      • Fusobacterium nucleatum
      • Fusobacterium periodonticum

    • Tannerella forsythia

      the first periodontal pathogen to be detected in endodontic infection.

    • Dialister (asaccharolytic obligately anaerobic Gram negative coccobacilli) :

      • Dialister pneumosintes
      • Dialister invisus.

    • Spirochetes -Treponema

      • are highly motile, spiral-shaped, Gram negative bacteria with periplasmic flagella. All oral spirochetes fall into the genus Treponema :
      • Treponema denticola
      • Treponema sacranskii
      • Treponema parvum
      • Treponema maltophilum and
      • Treponema lecithinolyticum
  • Gram positive
    • Gram positive anaerobic rods
      • Pseudoramibacter alactolyticus
      • Filifactor alocis
      • Actinomyces spp → banyak
      • Propionibacterium propionicum
      • Olsenella spp.
      • Slackia exigua
      • Mogibacterium timidum and
      • Eubacterium spp.
    • Gram positive cocci
      • Parvimonas micra (previously called Peptostreptococcus micros or Micromonas micros)
      • Streptococcus spp. include,
        • Streptococcus anginosus
        • Streptococcus mitisi,
        • Streptococcus sanguinis
      • Enterococcus faecalis.

• Extraradicular infections

  → bisa tembus defense barrier

  • In specific circumstances, microorganisms can overcome this defense barrier and establish an extraradicular infection.
  • This may lead to development of acute apical abscess with purulent inflammation in periapical tissue.
  • The extraradicular infections are dependent on or independent of an intraradicular infection. ( misal pathway dari membran periodontal, tidak lewat intraradicular)
  • dominant microorganisms → anaerobic bacteria
    • Actinomyces spp.
    • Propionibacterium propionicum
    • Treponema spp.
    • Porphyromonas endodontalis
    • Porphyromonas gingivalis
    • Treponema forsythia
    • Prevotella spp. and
    • Fusobacterium nucleatum.

Microflora involved in persistent infection

• Bacteria persisting intracanal disinfection procedures and after root canal treatment

  Some microorganisms are resistant to antimicrobial treatment and can survive in the root canal after biomechanical preparation.

  • Gram negative anaerobic rods
    • Fusobacterium nucleatum
    • Prevotella spp. and
    • Campylobacter rectus.
  • Gram positive bacteria

    • Enterococcus faecalis

      • Gram positive cocci and facultative anaerobes.
      • Enterococcus faecalis has been the predominant microbe in canals undergoing retreatment
      • E. faecalis was found in 77% of cases, confirming that this microbe is the most prevalent species in failed endodontic treatment
      • When this bacterium is present in small numbers, it is easily eliminated; but if it is in large numbers, it is difficult to eradicate.
      • E. faecalis has many distinct features which make it an exceptional survivor in the root canal. (Ciri beda jadi susah dieliminasi

      

      • Characteristic of E.faecalis :

        • Live and persist in poor nutrient environment
        • Survive in the presence of several medications (e.g., calcium hydroxide) and irrigants (e.g., sodium hypochlorite)
        • Form biofilms in medicated canals
        • Invade and metabolize fluids within the dentinal tubules and adhere to collagen
        • Acquire antibiotic resistance
        • Survive in extreme environments with low pH, high salinity and high temperatures
        • Endure prolonged periods of starvation and utilize tissue fluid that flows from the periodontal ligament (tidak ada sisa PD, pake cairan jaringan)

        

    • Streptococci

      (Streptococcus mitis, Streptococcus gordonii, Streptococcus anginosus, Streptococcus oralis)

    • Lactobacilli

      (Lactobacillus paracasei and Lactobacillus acidophilus)

    • Staphylococci

    • E. faecalis

    • Olsenella uli

    • Parvimonas micra

    • Pseudoramibacter alactolyticus

    • Propionibacterium spp.

    • Actinomyces spp.

    • Bifidobacterium spp.

    • sometimes: yeast (C. albicans)

Bacterial biofilms

• Virulence factor

  identification and characteristic of specific virulence factor that might play a role in endodontic infection

  • LPS (Lipopolysacharide)

    pada dinding sel bakteri gram negative tok

    = endotoxin → associated with pulpal pain, periapical inflammation,activation of complement, periapical bone destruction (membuat keradangan)

  • Eksotoxin

    trigger activation of T cells berlebih, menargetkan bakteri lain

    eg: bakteriosin→ toxin berprotein dihasilkan bakteri bisa membunuh bakteri lain

  • PG (Peptidoglycan)

    • pada dinding sel gram positive

    dilepaskan ketika bakteri lisis kemudian dia akan bereaksi dengan sistem kekebalan bawaan, ia akan mendorong peningkatan regulasi sitokin proinflamasi dan antiinflamasi dalam sel T→ adaptive immune response via macrophages

  • LTA (Lipoteichoic acid)

    • komponen bakteri gram +
    • shares many of its pathogenic properties with LPS

  • Fimbriae

    involved in attachment to surfaces and interactions with other bacteria

  • Capsules

    • lapisan terluar dari bakteri tersusun dari polisakarida
    • facilitate protection of the bacterial cell against desiccation, phagocytosis, bacterial viruses and hydrophobic toxic materials hydrophobic such as detergents

  • Extracellular proteins

    enzymes which are produced by bacteria

    • penyebebaran infeksi eg: enzim protease menetralkan immunoglobulin

  • Short- chain fatty acids

    • produk fermentasi bakteri anaerob obligat

    stimulate the inflammatory response and inflammatory cytokine release which contribute to infection process

• BACTERIAL BIOFILMS

  • What is it

    Biofilm is a mode of microbial growth where dynamic communities of interacting sessile cells are irreversibly attached to a solid substratum, as well as to each other, and are embedded in a self-made matrix of extracelullar

    • Bacteria can form biofilms on any surface that is bathed in a nutrient-containing fluid.
    • The three major components involved in biofilm formation are
      • bacterial cells,
      • a solid surface and
      • a fluid medium (ada nutrisi.
    • The microorganisms living in a community must have the following 4 basic criteria :
      • autopoiesis
        • possess the abilities to self-organize
      • homeostasis
        • resist environmental perturbations (gangguan)
      • synergy
        • be more effective in association than in isolation
      • communality
        • respond to environmental changes as a unit rather than single individuals
    • Endodontic Bacterial Biofilms
      • Microbial biofilm formation is typically seen on root canal walls
      • Microorganism are able to survive and induce persistent infection in periapical tissues
      • Category

        • intracanal biofilm

          terbentuk pada dentin saluran akar gigi endo

        • extraradicular biofilm

          biofilm permukaan akar terbentuk pada sementum berdekatan akar gigi yang terinfeksi endo

        • periapikal biofilm

        • biomaterial-centered infection

  • Conclusion

    • The presence of microorganism in the dental pulp is directly associated with the development of periapical disease
    • It is difficult to differentiate between the microorganisms remaining from primary or secondary infection.
    • Success of non-surgical endodontic treatment is limited by the heterogeneity (bentuk gigi) of patients and difficulty in maintaining standardized clinical conditions.
    • Knowledge and understanding of these persistent endodontic microbes helps to decide on surgical treatment or retreatment.
    • However, failure of root canal treatment sometimes occurs due to persistent or secondary intraradicular/ extraradicular infection